Concussion Management Policies and Procedures by Andrew Stabell

Table of Contents 1. 2. 3. 4. 5. 6. 7.

Mercer University Concussion Management Policies and Procedures......................................... 2 Concussion Management Procedural Outline .............................................................................. 16 Concussion Management Flow-Chart........................................................................................... 18 Physician Referral Checklist ........................................................................................................ 21 Post-Concussion Take Home Instructions ................................................................................... 22 Mercer University’s Compliance with NCAA Recommended Best Practices ............................ 23 Mercer University’s “Concussion Awareness Release” .............................................................. 25

References 1. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008 ................................................................................................................ 26 2. National Athletic Trainers’ Association Position Statement: Management of the Sport-Related Concussion, September 2004 ............................................................................................................................ 42 3. The Team Physician Consensus Statement: Concussion (Mild Traumatic Brain Injury) and the Team Physician, November 2005, edited 2006 ........................................................................................................ 60 4. NCAA Sports Medicine Handbook Guideline 2i Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete ........................................................................................................................................... 65 5. NCAA Memorandum April 29, 2010 “Concussion Management Plan” ...................................... 187 6. Behind the Blue Disk “NCAA Approach to Concussions 1/18/2010” ......................................... 192 7. Concussion Fact-Sheet for Student-Athletes ................................................................................ 193 8. Concussion Fact Sheet for Coaches .............................................................................................. 194 9. ImPACT Information Guide ......................................................................................................... 196 10. Sport Concussion Assessment Tool 2 (SCAT2) ........................................................................... 197 11. Pocket HIS-s ................................................................................................................................ 201 Supplemental Policies 1. 2. 3. 4. 5.

Mercer University Sports Medicine Emergency Action Plans ..................................................... 202 Coaches Acknowledgement Form for Emergency Management.................................................. 210 Positive Sickle Cell Notification to Coaches ................................................................................ 211 Scope of Practice .......................................................................................................................... 212 Sports Medicine Sport Assignments ............................................................................................. 214

Concussion Management Policy & Procedures In an effort to provide quality standards of care for our student-athletes, Mercer University’s Sports Medicine Department has established the following policy and procedural instructions for the management of concussions. The statements made in this policy are taken from the “Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008” and the “National Athletic Trainers’ Association Position Statement: Management of the Sport-Related Concussion, September 2004”. Statements have been modified from the original versions of these documents to provide a clear decision between options provided within the original documents or to better explain the adaptation of policy as it pertains specifically to Mercer University. Some statements have also been omitted which do not pertain to Mercer University. Other statements have been added which directly pertain to Mercer University’s policy. Original copies of these documents will be provided unedited following Mercer University’s policy for reference. BACKGROUND TO CONSENSUS PROCESS In November 2001, the 1st International Conference on Concussion in Sport was held in Vienna, Austria. This meeting was organized by the IIHF in partnership with FIFA and the Medical Commission of the IOC. As part of the resulting mandate for the future, the need for leadership and future updates were identified. The 2nd International Conference on Concussion in Sport was organized by the same group with the additional involvement of the IRB and was held in Prague, Czech Republic, in November 2004. The original aims of the symposia were to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, rugby, football (soccer) as well as other sports. To this end, a range of experts were invited to both meetings to address specific issues of epidemiology, basic and clinical science, injury grading systems, cognitive assessment, new research methods, protective equipment, management, prevention and long-term outcome. The 3rd International Conference on Concussion in Sport was held in Zurich, Switzerland, on 29/30 October 2008 and was designed as a formal consensus meeting following the organizational guidelines set forth by the US National Institutes of Health. (Details of the consensus methodology can be obtained at http://consensus.nih.gov/ABOUTCDP.htm.) The basic principles governing the conduct of a consensus development conference are summarized below: 1. A broad based non-government, non-advocacy panel was assembled to give balanced, objective and knowledgeable attention to the topic. Panel members excluded anyone with scientific or commercial conflicts of interest and included researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science. 2. These experts presented data in a public session, followed by inquiry and discussion. The panel then met in an executive session to prepare the consensus statement. 3. A number of specific questions were prepared and posed in advance to define the scope and guide the direction of the conference. The principle task of the panel was to elucidate responses to these questions. 4. A systematic literature review was prepared and circulated in advance for use by the panel in addressing the conference questions. 5. The consensus statement is intended to serve as the scientific record of the conference. 6. The consensus statement will be widely disseminated to achieve maximum impact on both current health care practice and future medical research. The panel chairperson (WM) did not identify with any advocacy position. The chairperson was responsible for directing the consensus session and guiding the panel’s deliberations. Panelists were drawn from clinical practice, academic and research in the field of sports related concussion. They do not represent organizations per se but were selected for their expertise, experience and understanding of this field.

1. CONCUSSION 1.1 Definition of 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 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. 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 neuro-imaging studies is seen in concussion. 2. CONCUSSION EVALUATION 2.1 CONCUSSION ASSESSMENT TOOLS Sports medicine clinicians are increasingly using standardized methods to obtain a more objective measurement of post-concussion signs and symptom (SCAT 2, HIS-s), cognitive dysfunction (SCAT 2, ImPACT), and postural instability (SCAT 2, BESS). These methods allow the clinician to quantify the severity of injury and measure the player’s progress over the course of post-injury recovery. An emerging model of sport concussion assessment involves the use of brief screening tools to evaluate postconcussion signs and symptoms, cognitive functioning, and postural stability on the sideline immediately after a concussion and neuropsychological testing to track recovery further out from the time of injury. Ultimately, these tests, when interpreted with the physical examination and other aspects of the injury evaluation, assist the ATC and other sports medicine professionals in the return to play decision-making process. 2.2 Symptoms and Signs of Acute Concussion The diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behavior, balance, sleep and cognition. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the SCAT2 form, which is an appendix to this document. The suspected diagnosis of concussion can include one or more of the following clinical domains: (a) Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (b) Physical signs (eg, loss of consciousness, amnesia) (c) Behavioral changes (eg, irritability) (d) Cognitive impairment (eg, slowed reaction times) (e) Sleep disturbance (eg, drowsiness) If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted. 2.3 On-field or Sideline Evaluation of Acute Concussion When a player 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 healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. (c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 or other similar tool such as the HIS-s.

(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 on the day of injury. Sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the Maddocks questions and the Standardized Assessment of Concussion (SAC). Both of these tests are included within the SCAT2. It is worth noting that standard orientation questions (eg, time, place) have been shown to be unreliable in the sporting situation when compared with memory assessment. It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which is sensitive to detect subtle deficits that may exist beyond the acute episode nor should they be used as a stand-alone tool for the ongoing management of sports concussions. It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode. Focal or posttraumatic intracranial mass lesions include subdural hematomas, epidural hematomas, cerebral contusions, and intracerebral hemorrhages and hematomas. These are considered uncommon in sport but are serious injuries; the ATC must be able to detect signs of clinical deterioration or worsening symptoms during serial assessments. Signs and symptoms of these focal vascular emergencies can include LOC, cranial nerve deficits, mental status deterioration, and worsening symptoms. Concern for a significant focal injury should also be raised if these signs or symptoms occur after an initial lucid period in which the athlete seemed normal. Not every sport-related concussion warrants immediate physician referral, but ATCs must be able to recognize those injuries that require further attention and provide an appropriate referral for advanced care, which may include neuro-imaging. Serial assessments and physician follow-up are important parts of the evaluation of the athlete with a concussion. Referrals should be made to medical personnel with experience managing sport-related concussion. The ATC should monitor vital signs and level of consciousness every 5 minutes after a concussion until the athlete’s condition stabilizes and improves. The athlete should also be monitored over the next few hours and days after the injury for delayed signs and symptoms and to assess recovery. The “Physician Referral Checklist” is an outline of scenarios that warrant physician referral or, in many cases, transport to the nearest hospital emergency department. The ATC-physician team must also consider referral options to specialists such as neurologists, neurosurgeons, neuropsychologists, and neuro-otologists, depending on the injury severity and situation. Referrals for imaging tests such as CT, MRI, or electronystagmography are also options that sometimes can aid in the diagnosis and/or management of sport-related concussion but are typically used only in cases involving LOC, severe amnesia, abnormal physical or neurologic findings, or increasing or intensified symptoms. 2.4 Evaluation in the Athletic Training Room or Emergency Room by Medical Personnel An athlete with concussion may be evaluated in the emergency room or doctor’s office as a point of first contact following injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this exam should encompass: (a) A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance. (b) A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury. (c) A determination of the need for emergent neuro-imaging in order to exclude a more severe brain injury involving a structural abnormality. In large part, these points above are included in the SCAT2 assessment, which forms part of the Zurich consensus statement.

3. CONCUSSION INVESTIGATIONS 3.1 Neuro-imaging Brain CT (or, where available, MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms. Newer structural MRI modalities including gradient echo, perfusion and diffusion imaging have greater sensitivity for structural abnormalities. However, the lack of published studies, as well as absent preinjury neuro-imaging data, limits the usefulness of this approach in clinical management at the present time. In addition, the predictive value of various MR abnormalities that may be incidentally discovered is not established at the present time. Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion. While not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting. A physicianâ&#x20AC;&#x2122;s prescription is required to perform any of the above imaging studies. 3.2 Objective Balance Assessment Published studies using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (eg, Balance Error Scoring System (BESS)), have identified postural stability deficits lasting approximately 72 hours following sport-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and should be considered a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where symptoms or signs indicate a balance component. A modified version of the BESS is included in the SCAT2. 3.3 Neuropsychological Assessment (ImPACT) The application of neuropsychological (NP) testing such as ImPACT in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation. Although in most case cognitive recovery largely overlaps with the time course of symptom recovery, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution suggesting that the assessment of cognitive function should be an important component in any return to play protocol. It must be emphasized, however, that NP assessment should not be the sole basis of management decisions; rather, it should be seen as an aid to the clinical decision making process in conjunction with a range of clinical domains and investigational results. Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training. However, there may be situations where neuropsychologists are not available and other medical professionals may perform or interpret NP screening tests. The ultimate return to play decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other (eg, formal balance assessment) testing, a more conservative return to play approach may be appropriate. In the majority of cases, NP testing will be used to assist return to play decisions and will not be done until the patient is symptom free. There may be situations (eg, child and adolescent athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining management. This will normally be best determined in consultation with a trained neuropsychologist. Baseline neuropsychological testing is recommended, when possible, to establish a normative level of neurocognitive functioning for individual athletes. Baseline neuropsychological testing typically takes 20 to 30 minutes per athlete. Sport concussion batteries should include measures of cognitive abilities most susceptible to change after concussion, including attention and concentration, cognitive processing (speed and efficiency), learning and memory, working memory, executive functioning, and verbal fluency. Tests of attention and concentration and memory functioning have been reported as the most sensitive to the acute effects of

concussion. The athlete’s age, sex, primary language, and level of education should be considered when selecting a test battery. Neuropsychological testing following a concussion will only be performed after the injured player reports that his or her symptoms are completely gone. This approach is based on the conceptual foundation that an athlete should not participate while symptomatic, regardless of neuropsychological test performance. Unnecessary serial neuropsychological testing, in addition to being burdensome and costly to the athlete and medical staff, also introduces practice effects that may confound the interpretation of performance in subsequent post injury testing sessions. Measuring ‘‘recovery’’ on neuropsychological tests and other clinical instruments is often a complex statistical matter, further complicated by practice effects and other psychometric dynamics affected by serial testing, even when pre-injury baseline data are available for individual athletes. The use of statistical models that empirically identify meaningful change while controlling for practice effects on serial testing may provide the clinician with the most precise benchmark in determining post injury recovery, above and beyond the simple conclusion that the player is ‘‘back to baseline.’’ The complexity of this analysis is the basis for the neuropsychologist overseeing the clinical interpretation of test data to determine injury severity and recovery. Further research is required to clarify the guidelines for determining and tracking recovery on specific measures after concussion. The clinician should also be aware that any concussion assessment tool, either brief screening instruments or more extensive neuropsychological testing, comes with some degree of risk for false negatives (eg, a player performs within what would be considered the normal range on the measure before actually reaching a complete clinical recovery after concussion). Therefore, test results should always be interpreted in the context of all clinical information, including the player’s medical history. Also, caution should be exercised in neuropsychological test interpretation when pre-injury baseline data do not exist. Numerous factors apart from the direct effects of concussion can influence test performance (Table 1). Table 1. Factors Influencing Neuropsychological Test Performance Medications, alcohol, or drugs Previous concussions Psychiatric disorders Educational background Learning disability Pre-injury level of cognitive functioning Attention deficit/hyperactivity Cultural background Certain medical conditions Age Primary language other than English Test anxiety Previous neuropsychological testing Distractions Sleep deprivation 4. CONCUSSION MANAGEMENT The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies. These are outlined in the section on modifiers below. The majority (80-90%) of concussions will recover spontaneously over several (7-10) days. In these situations, it is expected that an athlete will proceed progressively through a stepwise return to play strategy. During this period of recovery, while symptomatically following an injury, it is important to emphasize to the athlete that physical AND cognitive rest is required. Activities that require concentration and attention (eg, scholastic work, videogames, text messaging, etc.) may exacerbate symptoms and possibly delay recovery. In such cases, apart from limiting relevant physical and cognitive activities (and other risk-taking opportunities for re-injury), while symptomatic, no further intervention is required during the period of recovery, and the athlete typically resumes sport without further problem. The ATC must recognize that no 2 concussions are identical and that the resulting symptoms can be very different, depending on the force of the blow to the head, the degree of metabolic dysfunction, the tissue damage and duration of time needed to recover, the number of previous concussions, and the time between injuries. All these factors must be considered when managing an athlete suffering from cerebral concussion.

The two most recognizable signs of a concussion are LOC and amnesia; yet, as previously mentioned, neither is required for an injury to be classified as a concussion. A 2000 study of 1003 concussions sustained by high school and collegiate football players revealed that LOC and amnesia presented infrequently, 9% and 27% of all cases, respectively, whereas other signs and symptoms, such as headache, dizziness, confusion, disorientation, and blurred vision, were much more common. It has been suggested that LOC and amnesia, especially when prolonged, should not be ignored, but evidence for their usefulness in establishing return to play guidelines is scarce. Loss of consciousness, whether it occurs immediately or after an initially lucid interval, is important in that it may signify a more serious vascular brain injury. 4.1 Grading Scales Although it is common practice to use a grading scale on a wide variety of injuries, it is purely speculative to grade a concussion based on the initial assessment. In many cases, signs and symptoms may linger for a much longer time than might be expected based on their severity during initial evaluation. Grading is likely to be more important for treating subsequent injuries rather than for the progression of the current injury. Determining/grading the severity of the concussion should be avoided until the symptoms have resolved and return to play has been authorized. 4.2 Home Care Once it has been determined that a concussion has been sustained, a decision must be made as to whether the athlete can return home or should be considered for overnight observation or admission to the hospital. If the athlete is allowed to return home or to the dormitory room, the ATC should counsel a responsible friend, teammate, or parent to closely monitor the athlete. The teammate, parent, or friend must understand that the athlete should not be left alone. A concussion instruction form (Post-Concussion Take Home Instructions) should be given to the athlete and a responsible adult who will have direct contact with the athlete for the initial 24 hours after the injury. This form outlines signs and symptoms to watch for and provides useful recommendations on follow-up care. It should also suggest avoiding activities that may increase symptoms (eg, staying up late studying and physical education class) and should denote resuming normal activities of daily living, such as attending class and driving, once symptoms begin to resolve or decrease in severity. Traditionally, part of these instructions included a recommendation to wake up the athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. This recommendation has raised some debate about unnecessary wake-ups that disrupt the athleteâ&#x20AC;&#x2122;s sleep pattern and may increase symptoms the next day because of the combined effects of the injury and sleep deprivation. Serial monitoring during sleep is best performed in a hospital setting. If signs of deterioration are present or suspected, the athlete should be referred to the emergency room for observation. 4.3 Diet Evidence is limited to support the best type of diet for aiding in the recovery process after a concussion. A cascade of neurochemical, ionic, and metabolic changes occur after brain injury. Furthermore, some areas of the brain demonstrate glycolytic increases and go into a state of metabolic depression as a result of decreases in both glucose and oxidative metabolism with a reduction in cerebral blood flow. Some studies have suggested that severely brain-injured subjects unknowingly ate larger meals and increased their daily caloric intake when compared with controls. This may suggest the brain increases caloric intake to assist recovery. Although limited information is available regarding the recommended diet for the management of concussion, it is well accepted that athletes should be instructed to avoid alcohol, illicit drugs, and central nervous system medications that may interfere with cognitive function. A normal, well-balanced diet should be maintained to provide the needed nutrients to aid in the recovery process from the injury.

4.4 Graduated Return to Play Protocol Return to play protocol following a concussion follows a stepwise process as outlined in Table 2. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that an athlete would take approximately one week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed. This progression may be altered for athletes who are withheld for several weeks compared with those athletes withheld for just a few days. This process will be followed when the concussed individual is in a non-championship segment of the sport calendar. It is also highly recommended that this progression be followed when any of the modifying factors listed in section 5 of this document are conditional to the individual. Any changes to this progression must be approved by the team physician. TABLE 2. Graduated Return to Play Protocol Rehabilitation Stage 1. No Activity 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills

5. Full contact practice 6. Return to play

Functional Exercise Complete physical and cognitive rest Walking, swimming or stationary cycling keeping intensity <70% MPHR; no resistance training Skating drills, running drills, no head impact activities Progression to more complex training drills, eg. Passing drills; may start progressive resistance training Following medical clearance, participate in normal training activities Normal game play

Objective of Each Stage Recovery Increased HR Add movement Exercise, coordination, and cognitive load Restore confidence and assess functional skills by coaching staff

4.5 Individualized Assessment and Return to Play With adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources (eg, access to neuropsychologists, consultants, neuro-imaging, etc.), as well as access to immediate (ie, sideline) neuro-cognitive assessment, return to play management may be more rapid. The return to play strategy must still follow the same basic management principles, namely, full clinical and cognitive recovery before consideration of return to play. This approach is supported by published guidelines, such as the American Academy of Neurology, US Team Physician Consensus Statement, and US National Athletic Trainers’ Association Position Statement. This issue was extensively discussed by the consensus panelists, and it was acknowledged that there is evidence that some professional American football players are able to return to play more quickly, with even same day return to play supported by NFL studies without a risk of recurrence or sequelae. There is data, however, demonstrating that, at the collegiate and high school level, athletes allowed to return to play on the same day may demonstrate NP deficits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms. It should be emphasized, however, that the young (<18) elite athlete should be treated more conservatively even though the resources may be the same as an older professional athlete. (See section 6.1.) A team physician must authorize a more rapid return to play guideline. Many return to play guidelines call for the athlete to be symptom free for at least 7 days before returning to participation after a grade 1 or 2 concussion. Although many clinicians deviate from these recommendations and are more liberal in making return to play decisions, recent studies by Guskiewicz and McCrea et al suggest that perhaps the 7-day waiting period can minimize the risk of recurrent injury. On average, athletes required 7 days to fully recover after concussion. Same-season repeat injuries typically take place within a short window of time, 7 to 10 days after the first concussion, supporting the concept that there may be increased neuronal vulnerability or blood-flow changes during that time, similar to those reported by Giza, Hovda, et al in animal models. Returning an athlete to participation should follow a progression that begins once the athlete is completely symptom free. All signs and symptoms should be evaluated using a graded symptom scale or checklist (described in ‘‘Concussion Assessment Tools’’) when performing follow-up assessments and

should be evaluated both at rest and after exertional maneuvers such as biking, jogging, sit-ups, and pushups. Baseline measurements of neuropsychological and postural stability are strongly recommended for comparing with post-injury measurements. If these exertional tests do not produce symptoms, either acutely or in delayed fashion, the athlete can then participate in sport-specific skills that allow return to practice but should remain out of any activities that put him or her at risk for recurrent head injury. For the basketball player, this may include shooting baskets or participating in a walk-thru, and for the soccer player, this may include dribbling or shooting drills or other sport-specific activities. These restricted and monitored activities should be continued for the first few days after becoming symptom free. The athlete should be monitored periodically throughout and after these sessions to determine if any symptoms develop or increase in intensity. Before returning to full contact participation, the athlete should be reassessed using neuropsychological and postural-stability tests if available. If all scores have returned to baseline or better, return to full participation can be considered after further clinical evaluation. It is strongly recommended that after recurrent injury, especially within-season repeat injuries, the athlete be withheld for an extended period of time (approximately 7 days) after symptoms have resolved. 4.6 Psychological Management and Mental Health Issues In addition, psychological approaches may have potential application in this injury, particularly with the modifiers listed below. Care givers are also encouraged to evaluate the concussed athlete for affective symptoms such as depression, as these symptoms may be common in concussed athletes. 4.7 The Role of Pharmacological Therapy Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific prolonged symptoms (eg, sleep disturbance, anxiety, etc.). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. In broad terms, this approach to management should be only considered by clinicians experienced in concussion management. It has been suggested that concussed athletes avoid medications containing aspirin or non-steroidal antiinflammatories. These medications decrease platelet function and potentially increase intracranial bleeding, mask the severity and duration of symptoms, and possibly lead to a more severe injury. It is also recommended that acetaminophen (Tylenol, McNeil Consumer & Specialty Pharmaceuticals, Fort Washington, PA) be used sparingly in the treatment of headache-like symptoms in the athlete with a concussion. Other substances to avoid during the acute post-concussion period include those that adversely affect central nervous function, in particular alcohol and narcotics. An important consideration in return to play is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications (eg. Tylenol) that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician. 4.8 The Role of Pre-participation Concussion Evaluation Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value. Such a history may pre-identify athletes that fit into a high risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions. It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable. The clinical history should also include information about all previous head, face or cervical spine injuries, as these may also have clinical relevance. It is worth emphasizing that, in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history it is advised that details regarding protective equipment employed at time of injury be sought, both for recent and remote injuries.

The benefit a comprehensive pre-participation concussion evaluation allows for modification and optimization of protective behavior and is an opportunity for education. Data from objective measures of cognitive functioning, postural stability, and post-concussion signs and symptoms are most helpful in making a determination about severity of injury and post-injury recovery when pre-injury baseline data for an individual athlete are available. Baseline testing provides an indicator of what is ‘‘normal’’ for that particular athlete while also establishing the most accurate and reliable benchmark against which post-injury results can be compared. It is important to obtain a baseline symptom assessment in addition to baseline cognitive and other ability testing. Without baseline measures, the athlete’s post-injury performance on neuropsychological testing and other concussion assessment measures must be interpreted by comparison with available population normative values, which ideally are based on a large sample of the representative population. Normative data for competitive athletes on computerized neuropsychological tests and other concussion assessment measures are now more readily available from large-scale research studies, but baseline data on an individual athlete still provide the greatest clinical accuracy in interpreting post-injury test results. When performing baseline testing, a suitable testing environment eliminates all distractions that could alter the baseline performance and enhances the likelihood that all athletes are providing maximal effort. Most important, all evaluators should be aware of a test’s user requirements and be appropriately trained in the standardized instructions for test administration and scoring before embarking on baseline testing or adopting a concussion testing paradigm for clinical use. Several models exist for implementing baseline testing. Ideally, preseason baseline testing is conducted before athletes are exposed to the risk of concussion during sport participation. Some programs choose to conduct baseline testing as part of the pre-participation physical examination process. In this model, stations are established for various testing methods (eg, history collection, symptom assessment, neuropsychological testing, and balance testing), and athletes complete the evaluation sequence after being seen by the attending physician or ATC. This approach has the advantage of testing large groups of athletes in 1 session, while they are already in the mindset of undergoing a preseason physical examination. Collecting histories on individual athletes is also a vital part of baseline testing, especially in establishing whether the athlete has any history of concussion, neurologic disorder, or other remarkable medical conditions. Specifically with respect to concussion, it is important to establish (1) whether the player has any history of concussions and, if so, how many and (2) injury characteristics of previous concussions (eg, LOC, amnesia, symptoms, recovery time, time lost from participation, and medical treatment). For athletes with a history of multiple concussions, it is also important to clarify any apparent pattern of (1) concussions occurring as a result of lighter impacts, (2) concussions occurring closer together in time, (3) a lengthier recovery time with successive concussions, and (4) a less complete recovery with each injury. Documenting a history of attentional disorders, learning disability, or other cognitive development disorders is also critical, especially in interpreting an individual player’s baseline and post-injury performance on neuropsychological testing. If resources do not allow for preseason examinations in all athletes, at least a concerted effort to evaluate those athletes with a previous history of concussion should be made because of the awareness of increased risk for subsequent concussions in this group. 5. MODIFYING FACTORS IN CONCUSSION MANAGEMENT The consensus panel agreed that a range of “modifying” factors may influence the investigation and management of concussion and in some cases may predict the potential for prolonged or persistent symptoms. These modifiers would also be important to consider in a detailed concussion history and are outlined in Table 3.

Table 3: Concussion Modifiers Factors Modifier Symptoms Number Duration (>10) Severity Signs Prolonged LOC (>1min), amnesia Sequelae Concussive convulsions Temporal Frequency – repeated concussions over time Timing – injuries close together in time Recent history – recent concussion or TBI Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Age Child and adolescent (<18 years old) Co-and Pre-morbidities Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Psychoactive drugs, anticoagulants Behavior Dangerous style of play Sport High-risk activity, contact and collision sport, high sporting level In this setting, there may be additional management considerations beyond simple return to play advice. There may be a more important role for additional investigations including formal NP testing, balance assessment, and neuro-imaging. It is envisioned that athletes with such modifying features would be managed in a multidisciplinary manner coordinated by a physician with specific expertise in the management of concussive injury. The role of female gender as a possible modifier in the management of concussion was discussed at length by the panel. There was not unanimous agreement that the current published research evidence is conclusive that this should be included as a modifying factor, although it was accepted that gender may be a risk factor for injury and/or influence injury severity. 5.1 The Significance of Loss of Consciousness (LOC) In the overall management of moderate to severe traumatic brain injury, duration of LOC is an acknowledged predictor of outcome. While published findings in concussion describe LOC associated with specific early cognitive deficits, it has not been noted as a measure of injury severity. Consensus discussion determined that prolonged (<1 minute duration) LOC would be considered as a factor that may modify management. 5.2 The Significance of Amnesia and Other Symptoms There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity. Published evidence suggests that the nature, burden and duration of the clinical postconcussive symptoms may be more important than the presence or duration of amnesia alone. Further, it must be noted that retrograde amnesia varies with the time of measurement post-injury and hence is poorly reflective of injury severity. 5.3 Motor and Convulsive Phenomena A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.

5.4 Depression Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury including sports related concussion. Neuro-imaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression. 6. SPECIAL POPULATIONS 6.1 The Child and Adolescent Athlete There was unanimous agreement by the panel that the evaluation and management recommendations contained herein could be applied to children and adolescents down to the age of 10 years. Below that age children report concussion symptoms different from adults and would require age appropriate symptom checklists as a component of assessment. An additional consideration in assessing the child or adolescent athlete with a concussion is that in the clinical evaluation by the healthcare professional there may be the need to include both patient and parent input, as well as teacher and school input when appropriate. The decision to use NP testing is broadly the same as the adult assessment paradigm. However, timing of testing may differ in order to assist planning in school and home management (and may be performed while the patient is still symptomatic). If cognitive testing is performed then it must be developmentally sensitive until late teen years due to the ongoing cognitive maturation that occurs during this period which, in turn, makes the utility of comparison to either the person’s own baseline performance or to population norms limited. In this age group it is more important to consider the use of trained neuropsychologists to interpret assessment data, particularly in children with learning disorders and/or ADHD who may need more sophisticated assessment strategies. The panel strongly endorsed the view that children should not be returned to practice or play until clinically completely symptom free, which may require a longer time frame than for adults. In addition, the concept of “cognitive rest” was highlighted with special reference to a child’s need to limit exertion with activities of daily living and to limit scholastic and other cognitive stressors (eg, text messaging, videogames, etc.) while symptomatic. School attendance and activities may also need to be modified to avoid provocation of symptoms. Because of the different physiological responses and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative return to play approach is recommended. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. It is not appropriate for a child or adolescent athlete with concussion to return to play on the same day as the injury regardless of the level of athletic performance. Concussion modifiers apply even more to this population than adults and may mandate more cautious return to play advice. 6.2 Elite vs. Non-Elite Athletes The panel unanimously agreed that all athletes, regardless of level of participation, should be managed using the same treatment and return to play paradigm. A more useful construct was agreed whereby the available resources and expertise in concussion evaluation were of more importance in determining management than a separation between elite and non-elite athlete management. Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high-risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance. 6.3 Chronic Traumatic Brain Injury Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of chronic traumatic encephalopathy was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for long-term problems in the management of all athletes.

7. DISQUALIFYING THE STUDENT-ATHLETE 7.1 Disqualifying for the Season Guidelines from Cantu and the American Academy of Neurology both recommend termination of the season after the third concussion within the same season. The decision is more difficult if one of the injuries was more severe or was a severe injury resulting from a minimal blow, suggesting that the athlete’s brain may be at particular risk for recurrent injury. In addition, because many athletes participate in year-round activities, once they are disqualified for the ‘‘season,’’ it may be difficult to determine at what point they can resume contact play. Other issues without clear-cut answers in the literature are when to disqualify an athlete who has not been rendered unconscious and whose symptoms cleared rapidly or one who suffered multiple mild to moderate concussions throughout the career and whether youth athletes should be treated differently for initial and recurrent concussive injuries. In any case, the inability to resolve symptoms or the return of symptoms will preclude any return to play decisions. Additionally, persistent symptoms may provoke a consideration into acquiring a medical hardship or permanent disqualification. To qualify for a medical hardship, certain parameters must be met. An accurate description of these parameters can be found within the NCAA Division I Bylaw 14.2.4. As of 2010, both of the following criteria must be met: 1) The student-athlete must not have competed in more than 30% of the team’s scheduled contests, and 2) The student-athlete must not have competed in an event during the second half of the team’s championship segment. 7.2 Disqualifying for the Career When to disqualify an athlete for a career is a more difficult question to answer. The duration of symptoms may be a better criterion as to when to disqualify an athlete for the season or longer. Merril Hoge, Eric Lindros, Chris Miller, Al Toon, and Steve Young provide highly publicized cases of athletes sustaining multiple concussions with recurrent or post-concussion signs and symptoms that lasted for lengthy periods of time. Once an athlete has suffered a concussion, he or she is at increased risk for subsequent head injuries. Guskiewicz et al found that collegiate athletes had a 3-fold greater risk of suffering a concussion if they had sustained 3 or more previous concussions in a 7-year period and that players with 2 or more previous concussions required a longer time for total symptom resolution after subsequent injuries. Players also had a 3-fold greater risk for subsequent concussions in the same season, whereas recurrent, in-season injuries occurred within 10 days of the initial injury 92% of the time. In a similar study of high school athletes, Collins et al found that athletes with 3 or more prior concussions were at an increased risk of experiencing LOC (8-fold greater risk), anterograde amnesia (5.5-fold greater risk), and confusion (5.1fold greater risk) after subsequent concussion. Despite the increasing body of literature on this topic, debate still surrounds the question of how many concussions are enough to recommend ending the player’s career. Some research suggests that the magic number may be 3 concussions in a career. Although these findings are important, they should be carefully interpreted because concussions present in varying degrees of severity, and all athletes do not respond in the same way to concussive insults. Most important is that these data provide evidence for exercising caution when managing younger athletes with concussion and athletes with a history of previous concussions. Disqualification is often an emotional and traumatic event in the life of a student-athlete. The decision will be made by the Director of Sports Medicine in consultation with team physicians when it is determined that the student-athlete is at an unacceptable level of risk for permanent consequences as a result of participation or exertion. Once a decision is made to disqualify the student-athlete, a formal meeting should take place to discuss and explain the rationale for disqualification. Attendees should include the student-athlete, parents, the Director of Sports Medicine, the team’s Athletic Trainer, Head Coach, and other administrators as well as other medical representatives. 8. INJURY PREVENTION 8.1 Protective Equipment – Helmets and Headgear Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence.

Although wearing a helmet will not prevent all head injuries, a properly fitted helmet for certain sports reduces the risk of such injuries. A poorly fitted helmet is limited in the amount of protection it can provide, and the ATC must play a role in enforcing the proper fitting and use of the helmet. Protective sport helmets are designed primarily to prevent catastrophic injuries (ie, skull fractures and intracranial hematomas) and are not designed to prevent concussions. A helmet that protects the head from a skull fracture does not adequately prevent the rotational and shearing forces that lead to many concussions. The National Collegiate Athletic Association requires helmets be worn for the following sports: baseball, field hockey (goalkeepers only), football, ice hockey, women’s lacrosse (goalkeepers only), men’s lacrosse, and skiing. Helmets are also recommended for recreational sports such as bicycling, skiing, mountain biking, roller and inline skating, and speed skating. Headgear standards are established and tested by the National Operating Committee on Standards for Athletic Equipment and the American Society for Testing and Materials. More recently, the issue of headgear for soccer players has received much attention. Although several soccer organizations and governing bodies have approved the use of protective headbands in soccer, no published, peer-reviewed studies support their use. Recommendations supporting the use and performance of headgear for soccer are limited by a critical gap in biomechanical information about head impacts in the sport of soccer. Without data linking the severity and type of impacts and the clinical sequelae of single and repeated impacts, specifications for soccer headgear cannot be established scientifically. These types of headgear may reduce the ‘‘sting’’ of a head impact, yet they likely do not meet other sports headgear performance standards. This type of headgear may actually increase the incidence of injury. Players wearing headgear may have the false impression that the headgear will protect them during more aggressive play and thereby subject themselves to even more severe impacts that may not be attenuated by the headgear. 8.2 Protective Equipment – Mouth Guards The wearing of a mouth guard is thought by some to provide additional protection for the athlete against concussion by either reducing the risk of injury or reducing the severity of the injury itself. Mouth guards aid in the separation between the head of the condyle of the mandible and the base of the skull. It is thought that wearing an improperly fitted mouth guard or none at all increases this contact point. This theory, which is based on Newtonian laws of physics, suggests that the increased separation between 2 adjacent structures increases the time to contact, thus decreasing the amount of contact and decreasing the trauma done to the brain. However, no biomechanical studies support the theory that the increased separation results in less force being delivered to the brain. High school football and National Collegiate Athletic Association football rules mandate the wearing of a mouth guard, but the National Football League rulebook does not require players to wear a mouth guard. The National Collegiate Athletic Association requires mouth guards to be worn by all athletes in football, field hockey, ice hockey, and lacrosse. Researchers have found no advantage in wearing a custom-made mouth guard over a boil-and-bite mouth guard to reduce the rise of cerebral concussion in athletes. 8.3 Risk Compensation An important consideration in the use of protective equipment is the concept of risk compensation. This is where the use of protective equipment results in behavioral change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates from a false sense of security. 8.4 Aggression vs. Violence in Sport The competitive/aggressive nature of sport which makes it fun to play and watch should not be discouraged. However, sporting organizations should be encouraged to address violence that may increase concussion risk. Fair play and respect should be supported as key elements of sport.

9. KNOWLEDGE TRANSFER As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and health care providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe return to play. Methods to improve education including web-based resources, educational videos and international outreach programs are important in delivering the message. In addition, concussion working groups, plus the support and endorsement of enlightened sport groups such as Fe´de´ration Internationale de Football Association (FIFA), International Olympic Commission (IOC), International Rugby Board (IRB) and International Ice Hockey Federation (IIHF) who initiated this endeavor, have enormous value and must be pursued vigorously. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and managers play an important part in ensuring these values are implemented on the field of play. 10. MEDICAL LEGAL CONSIDERATIONS This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It provides an overview of issues that may be of importance to healthcare providers involved in the management of sports related concussion. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and is of a general nature consistent with the reasonable practice of a healthcare professional. Individual treatment will depend on the facts and circumstances specific to each individual case.

Concussion Management Procedural Outline I.

Staff Role Delineation A. Team Physicians 1. General oversight 2. Clinical evaluation 3. Changes to standard care 4. Authorization of progression 5. Release to the Care of the ATC for Return to Play B. Neuropsychologist 1. Interpretation of ImPACT 2. Recommendation and advisement in return to activity C. Various Specialists 1. Neurologists 2. Neurosurgeons 3. Neuro-otologists D. ATC 1. Implementation of the Concussion Management Policies and Procedures 2. Education of Athletes, Coaches, and Staff 3. Initial Assessment 4. Immediate Plan 5. Subsequent Evaluations and Monitoring 6. Referral Decisions 7. Follow-up Serial Evaluations 8. Communication with coaches and physicians 9. Initiation of Exertional Testing 10. Return to Play following Physician Release 11. Subsequent Inquires

II.

Assessment Tools A. SCAT-2 B. HIS-s C. ImPACT

III.

Education (Written & Verbal) A. Initial Team Meeting B. Coaches Meeting C. NCAA Materials D. Time of Injury

IV.

Baseline Testing A. Sports 1. Women’s Soccer 2. Volleyball 3. Men’s Soccer 4. Men’s Basketball 5. Women’s Basketball 6. Baseball 7. Softball 8. Lacrosse 9. Cheerleading B. Assessment Tools/Tests 1. SCAT-2 2. ImPACT

Pre-season Testing A. Performed during the initial physical process for incoming athletes B. Conducted prior to the first potential head injury training session

VI.

Injury Assessment A. On the field of play 1. HIS-s 2. SCAT-2 B. Serial Assessments 1. 5-15 min intervals 2. Constant Observation

VII.

Immediate Plan A. Referral B. Home Care Instructions

VIII.

Follow-up Plan A. Serial Assessments B. Resolution of Symptoms C. Exertional Testing D. Return to Play

IX.

Exertional Testing A. Progression to Sport Specific and full return a. No Activity i. Complete physical and cognitive rest b. Light Aerobic Exercise i. Walking, swimming, or stationary cycling keeping intensity bellow 70% of max heart rate; no resistance training c. Sport Specific Exercise i. Skating drill, running drills; no head impact activities d. Non-Contact Training Drills i. Progression to more complex training drills; passing drills & Progressive Resistance Exercise e. Full contact Practice i. Following medical clearance; participate in normal training activities f. Return To Play i. Normal game play B. Physician Changes a. Based on recurrence of symptoms or second insult b. Consideration given to modifiers

Return to Play A. Monitoring B. Re-Assessment

Concussion Management Sideline Evaluation

Suspected Head Injury

Immediate Referral Required?

YES

Immediate Referral Activate EMS/MERPO (478) 301-2911 Educate Athlete/Coaches/Roommates/Parents

NO YES

Symptoms Changing to Critical?

Sideline Concussion Evaluation HIS-s or SCAT 2

Continue Serial Evaluations Follow Take-Home Instructions Ensure Monitoring at Home Set Appointment for Follow-Up

Concussed Concussion Symptoms?

YES

Remove Athlete From Participation Educate Athlete/Coaches/Roommates Perform Serial Follow-up Evaluations Set up Physician Evaluation

NO Physically Exert (40 yd sprints & push-ups)

YES

Return to Play Re-Evaluate w/ HIS-s or SCAT2

Concussion Symptoms?

NO Monitor Athlete Closely Re-Evaluate Post-Game

Concussion Management Follow-Up Assessement Protocol

Perform Clinical Evaluation & SCAT2 12-48 Hours Post Concussion

Symptoms Changing to Critical?

Immediate Referral

YES

Transport to Emergency Facility or Activate EMS/MERPO (478) 301-2911 Educate Athlete/Coaches/Roommates/Parents

YES

Compare Baseline SCAT 2 to Follow-Up Scores

Symptoms Changing to Critical?

REST - NO ACTIVITY Return to Baseline ?

NO Schedule Follow-Up Routinely Frequent Evaluations Initially Progress to Every 2-3 Days

Perform Clinical Evaluation & SCAT2

YES Perform ImPACT Neuro-Psychological Testing

Compare Baseline ImPACT to Follow-Up Scores

NO Return to Baseline ?

YES YES Rest 24 Hours Then Proceed with Exertional Testing Protocol

Symptoms Return at Any Point?

Return to Play NO Monitor Athlete Closely Re-Evaluate As Needed

Concussion Management Exertional Testing Protoccol

Post-Concussion Testing Has Retunred to Baseline

Rest 24 Hours Then Proceed with Exertional Testing Protocol

Return to Baseline ?

Perform Aerobic Activity Bike 10 mins <70 Max HR

REST - NO ACTIVITY Symptoms Return?

YES

Remove From Activity Until Symptoms Resolve If Symptoms Persist Consider Extended Rest Between Exertional Testing

Perform Clinical Evaluation SCAT2 & ImPACT

NO Rest 24 Hours

Perform Sport Specific Drills Light Jog, Shooting No Head Contact

Symptoms Return?

YES

NO Rest 24 Hours

Perform Non-Contact Drills Increase Cognitive Load Begin Progressive Resistance

Symptoms Return?

YES

NO Rest 24 Hours

YES

Return to Play Perform Full-Contact Drills Resume Normal Activities

Symptoms Return?

Monitor Athlete Closely Re-Evaluate As Needed

Concussion Management Physician Referral Checklist

Day-of-injury referral 1. Loss of consciousness on the field 2. Amnesia lasting longer than 15 min 3. Deterioration of neurologic function* 4. Decreasing level of consciousness* 5. Decrease or irregularity in respirations* 6. Decrease or irregularity in pulse* 7. Increase in blood pressure 8. Unequal, dilated, or un-reactive pupils* 9. Cranial nerve deficits* 10. Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding* 11. Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation* 12. Seizure activity* 13. Vomiting 14. Motor deficits subsequent to initial on-field assessment 15. Sensory deficits subsequent to initial on-field assessment 16. Balance deficits subsequent to initial on-field assessment 17. Cranial nerve deficits subsequent to initial on-field assessment 18. Post-concussion symptoms that worsen 19. Additional post-concussion symptoms as compared with those on the field *Requires that the athlete be transported immediately to the nearest emergency department.

Delayed referral (after the day of injury) 1. Any of the findings in the day-of-injury referral category 2. Post-concussion symptoms worsen or do not improve over time 3. Increase in the number of post-concussion symptoms reported 4. Post-concussion symptoms begin to interfere with the athlete’s daily activities (ie, sleep disturbances)

Post-Concussion Take Home Instructions I believe that__________________________________ sustained a concussion or direct contact to the head on________________. This is a potentially dangerous or even life threatening situation To make sure he/she recovers, please follow the following important recommendations: 1. Please remind him/her to report to the athletic training room tomorrow at______________ for a follow-up evaluation. 2. Please review the items outlined on the enclosed Symptom Checklist. If any of these problems develop prior to his/her visit, please call ___________________________ at ______________________ or contact the local emergency medical system, 911, or your family physician. Otherwise, please follow the instructions outlined below. It is OK to: Use acetaminophen (Tylenol) for headaches Use ice pack on head and neck as needed for comfort Eat a normal diet Return to school Go to sleep There is NO need to: Check eyes with flashlight Wake up every hour Stay in bed

Avoid strenuous mental tasks Avoid text messaging and video games Do NOT use Advil, Ibuprofen, Aleve, or aspirin Do NOT drink alcohol Do NOT take pain killers or tranquilizers Do NOT eat spicy foods Do NOT drive until symptoms resolve Do NOT exercise or perform exertional activity

Specific recommendations: _______________________________________________________________________ Recommendations provided to: ___________________________________________________________________ Recommendations provided by: _________________________________ Date: ______________ Time: _________ Please feel free to contact me if you have any questions. I can be reached at: ________________________________ Signature: _______________________________ Date: ___________________

Symptom Checklist 1. Loss of consciousness – passed out 2. Excessive drowsiness 3. Increase in the severity of headache 4. Dizziness 5. Lack of coordination - unsteadiness 6. Change in speech pattern -slurring 7. Inability to concentrate 8. Blurred or double vision 9. Unequal pupil size 10. A stiff neck or pain around the neck or head 11. Any area of numbness, tingling, or weakness develops 12. Seizure activity or convulsions 13. Vomiting 14. Amnesia – has no memory or can’t remember 15 Change in behavior or emotional instability 16. Agitation or becomes easily aggravated 17. Loss of bowel or bladder function – inability to control going to the bathroom

Mercer University’s Compliance with NCAA Recommended Best Practices for a Concussion Management Plan for all NCAA Institutions 1. Institutions shall require student-athletes to sign a statement in which student-athletes accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes should be presented with educational material on concussions. (Concussion Fact-Sheet for Student-Athletes and Mercer University’s “Concussion Awareness Release”) 2. Institutions should have on file and annually update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. All athletics healthcare providers and coaches should review and practice the plan at least annually. (Mercer University Sports Medicine Emergency Action Plans, Coaches Acknowledgement Form for Emergency Management Positive Sickle Cell Notification to Coaches) 3.

Institutions should have on file an appropriate healthcare plan that includes equitable access to athletics healthcare providers for each NCAA sport. (NCAA Sports Medicine Handbook and Sports Medicine Sport Assignments)

4. Athletics healthcare providers should be empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. For example, a countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should they have sole hiring or firing authority over that provider. (Coaches Acknowledgement Form for Emergency Management) 5. Institutions shall have on file a written team physician–directed concussion management plan that specifically outlines the roles of athletics healthcare staff (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neuropsychologist). (Mercer University Concussion Management Policies and Procedures and Concussion Management Procedural Outline) In addition, the following components have been specifically identified for the collegiate environment: a. Institutions should ensure coaches have acknowledged they understand the concussion management plan, their role within the plan and that they received education about concussions. (Concussion Fact Sheet for Coaches and Coaches Acknowledgement Form for Emergency Management) b. Athletics healthcare providers should practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neurologist, neuropsychologist). (Scope of Practice and Concussion Management Procedural Outline) c. Institutions should record a baseline assessment for each student-athlete prior to the first practice in the sports of baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse, pole vaulting, rugby, soccer, softball, water polo, and wrestling, at a minimum. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment should consider one or more of the following areas of assessment. (Concussion Management Procedural Outline, Sport Concussion Assessment Tool 2 (SCAT2), and ImPACT Information Guide)

1) At a minimum, the baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments (e.g., SAC; SCAT; SCAT II; Balance Error Scoring System (BESS, Neurocom). (Concussion Management Procedural Outline, Sport Concussion Assessment Tool 2 (SCAT2), and ImPACT Information Guide) 2) Additionally, neuropsychological testing (e.g., computerized, standard paper and pencil) has been shown to be effective in the evaluation and management of concussion. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist. Ideally, post injury neuropsychological test data should be interpreted by a neuropsychologist. (Concussion Management Procedural Outline and ImPACT Information Guide) d. When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. (Concussion Management Procedural Outline) e. A student-athlete diagnosed with a concussion shall be withheld from the competition or practice and not return to activity for the remainder of that day. (Concussion Management Procedural Outline and Concussion Management Flow-Chart) f. The student-athlete should receive serial monitoring for deterioration. Athletes should be provided with written instructions upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions. (Concussion Management Procedural Outline and Post-Concussion Take Home Instructions) g. The student-athlete should be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play should follow a medically supervised stepwise process. (Concussion Management Procedural Outline, Concussion Management Flow-Chart, and Mercer University Concussion Management Policies and Procedures Table 2) h. Final authority for Return-to-Play shall reside with the team physician or the physicianâ&#x20AC;&#x2122;s designee. (Concussion Management Procedural Outline) 6. Institutions should document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. (Concussion Management Procedural Outline) 7. Although sports currently have rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced. (Concussion Fact-Sheet for StudentAthletes, Concussion Fact Sheet for Coaches, Coaches Acknowledgement Form for Emergency Management, and Concussion Management Procedural Outline) Â

Concussion Awareness Release This is to acknowledge that Mercer University has provided me with information about concussion and head related injuries. The following is a summary of the Mercer University Sports Medicine Concussion Management Plan. A concussion is caused by a blow to the head or body, or by a mechanism that jars the brain, and all concussions are a serious matter. You do not need to lose consciousness to have sustained a concussion. Research has demonstrated that the effects of repeated concussions are cumulative. Most athletes who experience an initial concussion can recover completely as long as they do not return to play prematurely. Following a concussion, there is a transient period of change in brain function that may last anywhere from 24 hours to several days. During this time, the brain is particularly vulnerable to more severe and even permanent injury. If an athlete sustains a second concussion during this period, the risk of permanent brain injury increases significantly. During this period, the consequences of a seemingly mild second concussion can be very severe, and several cases of death have been reported (ie. “second impact syndrome”). Prior to each season, all incoming athletes participating in collision or contact sports (Basketball, Baseball, Cheer, Lacrosse, Soccer, Volleyball, Softball) will undergo a baseline concussion assessment exam during pre-participation physicals. It is important to note that concussions can happen in any sport, however, and all injuries need to be reported immediately to a member of the Mercer Sports Medicine staff. Neuropsychological testing has proven to be an effective way to obtain useful data regarding the short-and long-term effects of mild traumatic brain injury. This will provide a proper baseline in which to compare post-concussion sign and symptom evaluations to assist in return to play decisions. Depending on the severity of the injury, it may be necessary for the athlete to be evaluated and/or released by a team physician or neurologist. The purpose of this awareness release to ensure that the athlete understands the importance of reporting all head injuries, including reporting all signs and symptoms to their athletic trainer or team physician. A concussed athlete is evaluated shortly following his or her concussion, and this information is used to determine the player’s post-concussion neuropsychological status. “Return to play” decisions are made on a case by case basis, and depend on the severity of the injury, as well as the length of time signs and symptoms are present post injury. By signing this, I, ______________________________, understand the risks involved in participating in sports at Mercer University. I have read and understood the concussion information sheet provided to me by Mercer Sports Medicine Staff. I agree to report all head injuries to my athletic trainer, including the reporting of all signs and symptoms related to my injury. I understand that each injury is different, and that each injury will be treated individually, with a return to play decision on an individual basis. I understand that I may need to be cleared by a team physician or a neurologist before a return to play decision may be made. By signing this, I agree to follow the direction of treatment and care designated by Mercer University sports medicine staff.

__________________________________ Student Athlete Signature

________________________________ Print Name

__________________________________ Parent Signature (if athlete under 18)

________________________________ Date

CONSENSUS STATEMENT

Consensus Statement on Concussion in Sport 3 International Conference on Concussion in Sport Held in Zurich, November 2008 rd

Paul McCrory, MBBS, PhD,* Willem Meeuwisse, MD, PhD,† Karen Johnston, MD, PhD,‡ Jiri Dvorak, MD,§ Mark Aubry, MD,k Mick Molloy, MB,¶ and Robert Cantu, MA, MD# (Clin J Sport Med 2009;19:185–200)

Preamble This paper is a revision and update of the recommendations developed following the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport.1,2 The Zurich Consensus statement is designed to build on the principles outlined in the original Vienna and Prague documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the ‘‘Background’’ section (see Section 11). This document is developed for use by physicians, therapists, certified athletic trainers, health professionals, coaches and other people involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving and therefore management and return to play decisions remain in the realm of clinical judgment on an individualized basis. Readers are

Submitted for publication January 14, 2009; accepted March 11, 2009. From the *Centre for Health, Exercise & Sports Medicine, University of Melbourne, Parkville, Australia; †Sport Medicine Centre, Faculty of Kinesiology, and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; ‡Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada; §FIFA Medical Assessment and Research Center (F-MARC) and Schulthess Clinic, Zurich, Switzerland; kInternational Ice Hockey Federation and Hockey Canada, and Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada; {International Rugby Board, Dublin, Ireland; and #Department of Neurosurgery and Department of Sport Medicine, Emerson Hospital, Concord, Massachusetts. Consensus panelists (listed in alphabetical order): In addition to the authors above, the consensus panelists were Steve Broglio, Gavin Davis, Randall Dick, Ruben Echemendia, Gerry Gioia, Kevin Guskiewicz, Stan Herring, Grant Iverson, Jim Kelly, Jamie Kissick, Michael Makdissi, Michael McCrea, Alain Ptito, Laura Purcell, and Margot Putukian. Also invited but not in attendance: Roald Bahr, Lars Engebretsen, Peter Hamlyn, Barry Jordan, and Patrick Schamasch. Competing Interests: The authors have no competing interests to declare. Reprints: not available. Correspondence: Assoc. Prof. Paul McCrory, MBBS, PhD, Centre for Health, Exercise & Sports Medicine, University of Melbourne, Parkville, Australia 3010 (e-mail: paulmccr@bigpond.net.au). Copyright Ó 2009 by Lippincott Williams & Wilkins

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encouraged to copy and distribute freely the Zurich Consensus document and/or the Sport Concussion Assessment Tool (SCAT2) card, and neither is subject to any copyright restriction. The authors request, however, that the document and/or the SCAT2 card be distributed in their full and complete format. The following focus questions formed the foundation for the Zurich concussion consensus statement:

Acute Simple Concussion Which symptom scale and which sideline assessment tool is best for diagnosis and/or follow up? How extensive should the cognitive assessment be in elite athletes? How extensive should clinical and neuropsychological (NP) testing be at non-elite level? Who should do/interpret the cognitive assessment? Is there a gender difference in concussion incidence and outcomes?

Return to Play (RTP) Issues

Is provocative exercise testing useful in guiding RTP? What is the best RTP strategy for elite athletes? What is the best RTP strategy for non-elite athletes? Is protective equipment (eg, mouthguards and helmets) useful in reducing concussion incidence and/or severity?

Complex Concussion and Long-term Issues Is the Simple versus Complex classification a valid and useful differentiation? Are there specific patient populations at risk of long-term problems? Is there a role for additional tests (eg, structural and/or functional MR Imaging, balance testing, biomarkers)? Should athletes with persistent symptoms be screened for depression/anxiety?

Paediatric Concussion Which symptoms scale is appropriate for this age group? Which tests are useful and how often should baseline testing be performed in this age group? What is the most appropriate RTP guideline for elite and non-elite child and adolescent athletes? www.cjsportmed.com |

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Future Directions What is the best method of knowledge transfer and education? Is there evidence that new and novel injury prevention strategies work (eg, changes to rules of the game, fair play strategies, etc.)? The Zurich document additionally examines the management issues raised in the previous Prague and Vienna documents and applies the consensus questions to these areas.

SPECIFIC RESEARCH QUESTIONS AND CONSENSUS DISCUSSION 1. CONCUSSION 1.1 Definition of Concussion Panel discussion regarding the definition of concussion and its separation from mild traumatic brain injury (mTBI) was held. Although there was acknowledgement that the terms refer to different injury constructs and should not be used interchangeably, it was not felt that the panel would define mTBI for the purpose of this document. There was unanimous agreement, however, that concussion is defined as follows: 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 either by a direct blow to the head, face, neck or elsewhere on the body with an ÔÔimpulsiveÕÕ force transmitted to the head. 2. Concussion typically results in the rapid onset of shortlived 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. 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.

1.2 Classification of Concussion There was unanimous agreement to abandon the Simple vs. Complex terminology that had been proposed in the Prague agreement statement, as the panel felt that the terminology itself did not fully describe the entities. However, the panel unanimously retained the concept that the majority (80%90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents.2

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2. CONCUSSION EVALUATION 2.1 Symptoms and Signs of Acute Concussion The panel agreed that the diagnosis of acute concussion usually involves the assessment of a range of domains including clinical symptoms, physical signs, behavior, balance, sleep and cognition. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination. The detailed clinical assessment of concussion is outlined in the SCAT2 form, which is an appendix to this document. The suspected diagnosis of concussion can include one or more of the following clinical domains: (a) Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability) (b) Physical signs (eg, loss of consciousness, amnesia) (c) Behavioural changes (eg, irritablity) (d) Cognitive impairment (eg, slowed reaction times) (e) Sleep disturbance (eg, drowsiness) If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted.

2.2 On-field or Sideline Evaluation of Acute Concussion When a player 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 healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged. (c) Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 or other similar tool. (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 on the day of injury. Occasionally, in adult athletes, there may be return to play on the same day as the injury. (See section 4.2.) It was unanimously agreed that sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports this may require rule change to allow an off-field medical assessment to occur without affecting the flow of the game or unduly penalizing the injured player’s team. Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the Maddocks questions3,4 and the Standardized q 2009 Lippincott Williams & Wilkins

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Assessment of Concussion (SAC).5–7 It is worth noting that standard orientation questions (eg, time, place, person) have been shown to be unreliable in the sporting situation when compared with memory assessment.4,8 It is recognized, however, that abbreviated testing paradigms are designed for rapid concussion screening on the sidelines and are not meant to replace comprehensive neuropsychological testing which is sensitive to detect subtle deficits that may exist beyond the acute episode nor should they be used as a stand-alone tool for the ongoing management of sports concussions. It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode.

abnormalities that may be incidentally discovered is not established at the present time. Other imaging modalities such as fMRI demonstrate activation patterns that correlate with symptom severity and recovery in concussion.9–13 Whilst not part of routine assessment at the present time, they nevertheless provide additional insight to pathophysiological mechanisms. Alternative imaging technologies (eg, positron emission tomography, diffusion tensor imaging, magnetic resonance spectroscopy, functional connectivity), while demonstrating some compelling findings, are still at early stages of development and cannot be recommended other than in a research setting.

2.3 Evaluation in Emergency Room or Office by Medical Personnel

3.2 Objective Balance Assessment

An athlete with concussion may be evaluated in the emergency room or doctor’s office as a point of first contact following injury or may have been referred from another care provider. In addition to the points outlined above, the key features of this exam should encompass: (a) A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning and gait and balance. (b) A determination of the clinical status of the patient including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitness to the injury. (c) A determination of the need for emergent neuroimaging in order to exclude a more severe brain injury involving a structural abnormality. In large part, these points above are included in the SCAT2 assessment, which forms part of the Zurich consensus statement.

3. CONCUSSION INVESTIGATIONS A range of additional investigations may be utilized to assist in the diagnosis and/or exclusion of injury. These include:

3.1 Neuroimaging It was recognized by the panelists that conventional structural neuroimaging is normal in concussive injury. Given that caveat, the following suggestions are made: Brain CT (or, where available, MR brain scan) contributes little to concussion evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists. Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms. Newer structural MRI modalities including gradient echo, perfusion and diffusion imaging have greater sensitivity for structural abnormalities. However, the lack of published studies, as well as absent pre-injury neuroimaging data, limits the usefulness of this approach in clinical management at the present time. In addition, the predictive value of various MR q 2009 Lippincott Williams & Wilkins

Published studies using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (eg, Balance Error Scoring System (BESS)), have identified postural stability deficits lasting approximately 72 hours following sport-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic functioning and should be considered a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where symptoms or signs indicate a balance component.14–20

3.3 Neuropsychological Assessment The application of neuropsychological (NP) testing in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation.21–26 Although in most case cognitive recovery largely overlaps with the time course of symptom recovery, it has been demonstrated that cognitive recovery may occasionally precede or more commonly follow clinical symptom resolution suggesting that the assessment of cognitive function should be an important component in any return to play protocol.27,28 It must be emphasized, however, that NP assessment should not be the sole basis of management decisions; rather, it should be seen as an aid to the clinical decisionmaking process in conjunction with a range of clinical domains and investigational results. Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training. However, there may be situations where neuropsychologists are not available and other medical professionals may perform or interpret NP screening tests. The ultimate return to play decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other (eg, formal balance assessment) testing, a more conservative return to play approach may be appropriate. In the majority of cases, NP testing will be used to assist return to play decisions and will not be done until the patient is symptom free.29,30 There may be situations (eg, child and adolescent athletes) where testing may be performed early whilst the patient is still symptomatic to assist in determining management. This will normally be best determined in consultation with a trained neuropsychologist.31,32 www.cjsportmed.com |

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3.4 Genetic Testing The significance of Apolipoprotein (Apo) E4, ApoE promotor gene, Tau polymerase and other genetic markers in the management of sports concussion risk or injury outcome is unclear at this time.33,34 Evidence from human and animal studies in more severe traumatic brain injury demonstrates induction of a variety of genetic and cytokine factors such as: insulin-like growth factor-1 (IGF-1), IGF binding protein-2, Fibroblast growth factor, Cu-Zn superoxide dismutase, superoxide dismutase-1 (SOD-1), nerve growth factor, glial fibrillary acidic protein (GFAP) and S-100. Whether such factors are affected in sporting concussion is not known at this stage.35–42

3.5 Experimental Concussion Assessment Modalities Different electrophysiological recording techniques (eg, evoked response potential (ERP), cortical magnetic stimulation and electroencephalography) have demonstrated reproducible abnormalities in the post concussive state; however, not all studies reliably differentiated concussed athletes from controls.43–49 The clinical significance of these changes remains to be established. In addition, biochemical serum and cerebral spinal fluid markers of brain injury (including S-100, neuron specific enolase (NSE), myelin basic protein (MBP), GFAP, tau, etc.) have been proposed as means by which cellular damage may be detected if present.50–56 There is currently insufficient evidence, however, to justify the routine use of these biomarkers clinically.

4. CONCUSSION MANAGEMENT The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. The recovery and outcome of this injury may be modified by a number of factors that may require more sophisticated management strategies. These are outlined in the section on modifiers below. As described above, the majority of injuries will recover spontaneously over several days. In these situations, it is expected that an athlete will proceed progressively through a stepwise return to play strategy.57 During this period of

recovery, while symptomatically following an injury, it is important to emphasize to the athlete that physical AND cognitive rest is required. Activities that require concentration and attention (eg, scholastic work, videogames, text messaging, etc.) may exacerbate symptoms and possibly delay recovery. In such cases, apart from limiting relevant physical and cognitive activities (and other risk-taking opportunities for re-injury), while symptomatic, no further intervention is required during the period of recovery, and the athlete typically resumes sport without further problem.

4.1 Graduated Return to Play Protocol Return to play protocol following a concussion follows a stepwise process as outlined in Table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that an athlete would take approximately one week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed.

4.2 Same Day RTP With adult athletes, in some settings, where there are team physicians experienced in concussion management and sufficient resources (eg, access to neuropsychologists, consultants, neuroimaging, etc.), as well as access to immediate (ie, sideline) neuro-cognitive assessment, return to play management may be more rapid. The RTP strategy must still follow the same basic management principles, namely, full clinical and cognitive recovery before consideration of return to play. This approach is supported by published guidelines, such as the American Academy of Neurology, US Team Physician Consensus Statement, and US National Athletic Trainers’ Association Position Statement.58–60 This issue was extensively discussed by the consensus panelists, and it was acknowledged that there is evidence that some professional American football players are able to RTP more quickly, with even same day RTP supported by NFL studies without a risk of recurrence or sequelae.61 There is data, however, demonstrating that, at the collegiate and high school level, athletes

TABLE 1. Graduated Return to Play Protocol Rehabilitation Stage 1. No activity 2. Light aerobic exercise 3. Sport-specific exercise 4. Non-contact training drills

5. Full contact practice 6. Return to play

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Functional Exercise at Each Stage of Rehabilitation Complete physical and cognitive rest Walking, swimming or stationary cycling keeping intensity ,70% MPHR; no resistance training Skating drills in ice hockey, running drills in soccer; no head impact activities Progression to more complex training drills, eg, passing drills in football and ice hockey; may start progressive resistance training Following medical clearance, participate in normal training activities Normal game play

Objective of Each Stage Recovery Increase HR Add movement Exercise, coordination, and cognitive load

Restore confidence and assess functional skills by coaching staff

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allowed to RTP on the same day may demonstrate NP deficits post-injury that may not be evident on the sidelines and are more likely to have delayed onset of symptoms.62–68 It should be emphasized, however, that the young (,18) elite athlete should be treated more conservatively even though the resources may be the same as an older professional athlete. (See section 6.1.)

4.3 Psychological Management and Mental Health Issues In addition, psychological approaches may have potential application in this injury, particularly with the modifiers listed below.69,70 Care givers are also encouraged to evaluate the concussed athlete for affective symptoms such as depression, as these symptoms may be common in concussed athletes.57

4.4 The Role of Pharmacological Therapy Pharmacological therapy in sports concussion may be applied in two distinct situations. The first of these situations is the management of specific prolonged symptoms (eg, sleep disturbance, anxiety, etc.). The second situation is where drug therapy is used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms.71 In broad terms, this approach to management should be only considered by clinicians experienced in concussion management. An important consideration in RTP is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion. Where antidepressant therapy may be commenced during the management of a concussion, the decision to return to play while still on such medication must be considered carefully by the treating clinician.

4.5 The Role of Pre-participation Concussion Evaluation Recognizing the importance of a concussion history, and appreciating the fact that many athletes will not recognize all the concussions they may have suffered in the past, a detailed concussion history is of value.72–75 Such a history may preidentify athletes that fit into a high risk category and provides an opportunity for the healthcare provider to educate the athlete in regard to the significance of concussive injury. A structured concussion history should include specific questions as to previous symptoms of a concussion, not just the perceived number of past concussions. It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable.72 The clinical history should also include information about all previous head, face or cervical spine injuries, as these may also have clinical relevance. It is worth emphasizing that, in the setting of maxillofacial and cervical spine injuries, coexistent concussive injuries may be missed unless specifically assessed. Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. As part of the clinical history it is advised that details regarding q 2009 Lippincott Williams & Wilkins

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protective equipment employed at time of injury be sought, both for recent and remote injuries. The benefit a comprehensive pre-participation concussion evaluation allows for modification and optimization of protective behavior and is an opportunity for education.

5. MODIFYING FACTORS IN CONCUSSION MANAGEMENT The consensus panel agreed that a range of ÔmodifyingÕ factors may influence the investigation and management of concussion and in some cases may predict the potential for prolonged or persistent symptoms. These modifiers would also be important to consider in a detailed concussion history and are outlined in Table 2. In this setting, there may be additional management considerations beyond simple RTP advice. There may be a more important role for additional investigations including formal NP testing, balance assessment, and neuroimaging. It is envisioned that athletes with such modifying features would be managed in a multidisciplinary manner coordinated by a physician with specific expertise in the management of concussive injury. The role of female gender as a possible modifier in the management of concussion was discussed at length by the panel. There was not unanimous agreement that the current published research evidence is conclusive that this should be included as a modifying factor, although it was accepted that gender may be a risk factor for injury and/or influence injury severity.76–78

5.1 The Significance of Loss of Consciousness (LOC) In the overall management of moderate to severe traumatic brain injury, duration of LOC is an acknowledged

TABLE 2. Concussion Modifiers Factors Symptoms

Signs Sequelae Temporal

Threshold

Age Co- and Pre-morbidities

Medication Behaviour Sport

Modifier Number Duration (.10 days) Severity Prolonged LOC (.1 min), amnesia Concussive convulsions Frequency - repeated concussions over time Timing - injuries close together in time ‘‘Recency’’ - recent concussion or TBI Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Child and adolescent (,18 years old) Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Psychoactive drugs, anticoagulants Dangerous style of play High-risk activity, contact and collision sport, high sporting level

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predictor of outcome.79 Whilst published findings in concussion describe LOC associated with specific early cognitive deficits, it has not been noted as a measure of injury severity.80,81 Consensus discussion determined that prolonged (.1 minute duration) LOC would be considered as a factor that may modify management.

5.2 The Significance of Amnesia and Other Symptoms There is renewed interest in the role of post-traumatic amnesia and its role as a surrogate measure of injury severity.67,82,83 Published evidence suggests that the nature, burden and duration of the clinical post-concussive symptoms may be more important than the presence or duration of amnesia alone.80,84,85 Further, it must be noted that retrograde amnesia varies with the time of measurement post-injury and hence is poorly reflective of injury severity.86,87

5.3 Motor and Convulsive Phenomena A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.88,89

5.4 Depression Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury including sports related concussion. Neuroimaging studies using fMRI suggest that a depressed mood following concussion may reflect an underlying pathophysiological abnormality consistent with a limbic-frontal model of depression.52,90–100

6. SPECIAL POPULATIONS 6.1 The Child and Adolescent Athlete There was unanimous agreement by the panel that the evaluation and management recommendations contained herein could be applied to children and adolescents down to the age of 10 years. Below that age children report concussion symptoms different from adults and would require ageappropriate symptom checklists as a component of assessment. An additional consideration in assessing the child or adolescent athlete with a concussion is that in the clinical evaluation by the healthcare professional there may be the need to include both patient and parent input, as well as teacher and school input when appropriate.101–107 The decision to use NP testing is broadly the same as the adult assessment paradigm. However, timing of testing may differ in order to assist planning in school and home management (and may be performed while the patient is still symptomatic). If cognitive testing is performed then it must be developmentally sensitive until late teen years due to the ongoing cognitive maturation that occurs during this period which, in turn, makes the utility of comparison to either the person’s own baseline performance or to population norms limited.20 In this age group it is more important to consider the use of trained neuropsychologists to interpret assessment data, particularly in children with learning disorders and/or

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ADHD who may need more sophisticated assessment strategies.31,32,101 The panel strongly endorsed the view that children should not be returned to practice or play until clinically completely symptom free, which may require a longer time frame than for adults. In addition, the concept of Ôcognitive restÕ was highlighted with special reference to a child’s need to limit exertion with activities of daily living and to limit scholastic and other cognitive stressors (eg, text messaging, videogames, etc.) while symptomatic. School attendance and activities may also need to be modified to avoid provocation of symptoms. Because of the different physiological responses and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative return to play approach is recommended. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. It is not appropriate for a child or adolescent athlete with concussion to RTP on the same day as the injury regardless of the level of athletic performance. Concussion modifiers apply even more to this population than adults and may mandate more cautious RTP advice.

6.2 Elite vs. Non-Elite Athletes The panel unanimously agreed that all athletes, regardless of level of participation, should be managed using the same treatment and return to play paradigm. A more useful construct was agreed whereby the available resources and expertise in concussion evaluation were of more importance in determining management than a separation between elite and non-elite athlete management. Although formal baseline NP screening may be beyond the resources of many sports or individuals, it is recommended that in all organized high-risk sports consideration be given to having this cognitive evaluation regardless of the age or level of performance.

6.3 Chronic Traumatic Brain Injury Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuro-pathological evidence of chronic traumatic encephalopathy was observed in retired football players.108–112 Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for longterm problems in the management of all athletes.

7. INJURY PREVENTION 7.1 Protective Equipment – Mouthguards and Helmets There is no good clinical evidence that currently available protective equipment will prevent concussion, although mouthguards have a definite role in preventing dental and oro-facial injury. Biomechanical studies have shown a reduction in impact forces to the brain with the use of head gear and helmets, but these findings have not been translated to show a reduction in concussion incidence. For q 2009 Lippincott Williams & Wilkins

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skiing and snowboarding, there are a number of studies to suggest that helmets provide protection against head and facial injury and hence should be recommended for participants in alpine sports.113–116 In specific sports such as cycling, motor and equestrian sports, protective helmets may prevent other forms of head injury (eg, skull fracture) that are related to falling on hard road surfaces, and these may be an important injury prevention issue for those sports.116–128

7.2 Rule Change Consideration of rule changes to reduce head injury incidence or severity may be appropriate where a clear-cut mechanism is implicated in a particular sport. An example of this is in football (soccer) where research studies demonstrated that upper limb to head contact in heading contests accounted for approximately 50% of concussions.129 As noted earlier, rule changes also may be needed in some sports to allow an effective off-field medical assessment to occur without compromising the athlete’s welfare, affecting the flow of the game or unduly penalizing the player’s team. It is important to note that rule enforcement may be a critical aspect of modifying injury risk in these settings, and referees play an important role in this regard.

7.3 Risk Compensation An important consideration in the use of protective equipment is the concept of risk compensation.130 This is where the use of protective equipment results in behavioral change such as the adoption of more dangerous playing techniques, which can result in a paradoxical increase in injury rates. This may be a particular concern in child and adolescent athletes where head injury rates are often higher than in adult athletes.131–133

7.4 Aggression vs. Violence in Sport The competitive/aggressive nature of sport which makes it fun to play and watch should not be discouraged. However, sporting organizations should be encouraged to address violence that may increase concussion risk.134,135 Fair play and respect should be supported as key elements of sport.

8. KNOWLEDGE TRANSFER As the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes, colleagues and the general public is a mainstay of progress in this field. Athletes, referees, administrators, parents, coaches and health care providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe return to play. Methods to improve education including web-based resources, educational videos and international outreach programs are important in delivering the message. In addition, concussion working groups, plus the support and endorsement of enlightened sport groups such as Fe´de´ration Internationale de Football Association (FIFA), International Olympic Commission (IOC), International Rugby Board (IRB) and International Ice Hockey Federation (IIHF) who initiated this endeavor, have enormous value and must be pursued vigorously. Fair play and respect for opponents are ethical values that should be encouraged in all sports and sporting associations. Similarly, coaches, parents and q 2009 Lippincott Williams & Wilkins

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managers play an important part in ensuring these values are implemented on the field of play.57,136–148

9. FUTURE DIRECTIONS The consensus panelists recognize that research is needed across a range of areas in order to answer some critical research questions. The key areas for research identified include: Validation of the SCAT2 Gender effects on injury risk, severity and outcome Paediatric injury and management paradigms Virtual reality tools in the assessment of injury Rehabilitation strategies (eg, exercise therapy) Novel imaging modalities and their role in clinical assessment Concussion surveillance using consistent definitions and outcome measures Clinical assessment where no baseline assessment has been performed ÔBest-practiceÕ neuropsychological testing Long-term outcomes On-field injury severity predictors

10. MEDICAL LEGAL CONSIDERATIONS This consensus document reflects the current state of knowledge and will need to be modified according to the development of new knowledge. It provides an overview of issues that may be of importance to healthcare providers involved in the management of sports related concussion. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and is of a general nature consistent with the reasonable practice of a healthcare professional. Individual treatment will depend on the facts and circumstances specific to each individual case. It is intended that this document will be formally reviewed and updated prior to 1 December 2012.

11. STATEMENT ON BACKGROUND TO CONSENSUS PROCESS In November 2001, the 1st International Conference on Concussion in Sport was held in Vienna, Austria. This meeting was organized by the IIHF in partnership with FIFA and the Medical Commission of the IOC. As part of the resulting mandate for the future, the need for leadership and future updates were identified. The 2nd International Conference on Concussion in Sport was organized by the same group with the additional involvement of the IRB and was held in Prague, Czech Republic, in November 2004. The original aims of the symposia were to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in ice hockey, rugby, football (soccer) as well as other sports. To this end, a range of experts were invited to both meetings to address specific issues of epidemiology, basic and clinical science, injury grading systems, cognitive assessment, new research methods, protective equipment, management, prevention and long-term outcome.1,2 The 3rd International Conference on Concussion in Sport was held in Zurich, Switzerland, on 29/30 October 2008 and was designed as a formal consensus meeting following the organizational guidelines set forth by the US National www.cjsportmed.com |

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Institutes of Health. (Details of the consensus methodology can be obtained at http://consensus.nih.gov/ABOUTCDP. htm.) The basic principles governing the conduct of a consensus development conference are summarized below: 1. A broad based non-government, non-advocacy panel was assembled to give balanced, objective and knowledgeable attention to the topic. Panel members excluded anyone with scientific or commercial conflicts of interest and included researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science. 2. These experts presented data in a public session, followed by inquiry and discussion. The panel then met in an executive session to prepare the consensus statement. 3. A number of specific questions were prepared and posed in advance to define the scope and guide the direction of the conference. The principle task of the panel was to elucidate responses to these questions. These questions are outlined above. 4. A systematic literature review was prepared and circulated in advance for use by the panel in addressing the conference questions. 5. The consensus statement is intended to serve as the scientific record of the conference. 6. The consensus statement will be widely disseminated to achieve maximum impact on both current health care practice and future medical research. The panel chairperson (WM) did not identify with any advocacy position. The chairperson was responsible for directing the consensus session and guiding the panel’s deliberations. Panelists were drawn from clinical practice, academic and research in the field of sports related concussion. They do not represent organisations per se but were selected for their expertise, experience and understanding of this field.

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113. Hagel BE, Pless IB, Goulet C, et al. Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study. BMJ. 2005; 330:281–283. 114. McCrory P. The role of helmets in skiing and snowboarding. Br J Sports Med. 2002;36:314. 115. Mueller BA, Cummings P, Rivara FP, et al. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology. 2008;19:270–276. 116. Sulheim S, Holme I, Ekeland A, et al. Helmet use and risk of head injuries in alpine skiers and snowboarders. JAMA. 2006;295: 919–924. 117. Delaney JS, Al-Kashmiri A, Drummond R, et al. The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players. Br J Sports Med. 2008;42:110–115; discussion, 5. 118. Viano DC, Pellman EJ, Withnall C, et al. Concussion in professional football: performance of newer helmets in reconstructed game impacts– part 13. Neurosurgery. 2006;59:591–606; discussion, 591–606. 119. Finch C, Braham R, McIntosh A, et al. Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial. Inj Prev. 2005;11:242–246. 120. McIntosh A, McCrory P. The dynamics of concussive head impacts in rugby and Australian rules football. Med Sci Sports Exerc. 2000;32: 1980–1985. 121. McIntosh A, McCrory P. Impact energy attenuation performance of football headgear. Br J Sports Med. 2000;34:337–342. 122. McIntosh A, McCrory P. Effectiveness of headgear in a pilot study of under 15 rugby union football. Br J Sports Med. 2001;35:167–170. 123. McIntosh A, McCrory P, Finch C, et al. Rugby Headgear Study Report. Faculty of Science, School of Safety Sciences, The University of New South Wales, Sydney, Australia, May 2005. 124. Finch CF, Newstead SV, Cameron MH, et al. Head injury reductions in Victoria two years after the introduction of mandatory bicycle helmet use. http://www.monash.edu.au/muarc/reports/muarc051.pdf. Monash University Accident Research Centre. Published July 1993. 125. Curnow WJ. Bicycle helmets and public health in Australia. Health Promot J Austr. 2008;19:10–15. 126. Hewson PJ. Cycle helmets and road casualties in the UK. Traffic Inj Prev. 2005;6:127–134. 127. Davidson JA. Epidemiology and outcome of bicycle injuries presenting to an emergency department in the United Kingdom. Eur J Emerg Med. 2005;12:24–29. 128. Hansen KS, Engesaeter LB, Viste A. Protective effect of different types of bicycle helmets. Traffic Inj Prev. 2003;4:285–290. 129. Andersen T, Arnason A, Engebretsen L, et al. Mechanism of head injuries in elite football. Br J Sports Med. 2004;38:690–696. 130. Hagel B, Meewisse W. Risk compensation: a ‘‘side effect’’ of sport injury prevention [editorial]? Clin J Sport Med. 2004;14:193–196. 131. Finch C, Mcintosh AS, McCrory P, et al. A pilot study of the attitudes of Australian Rules footballers towards protective headgear. J Sci Med Sport. 2003;6:505–511. 132. Finch CF, McIntosh AS, McCrory P. What do under 15 year old schoolboy rugby union players think about protective headgear? Br J Sports Med. 2001;35:89–94. 133. Finch CF, McIntosh AS, McCrory P, et al. A pilot study of the attitudes of Australian Rules footballers towards protective headgear. J Sci Med Sport. 2003;6:505–511. 134. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med. 2000;154:11–15. 135. Shaw NH. Bodychecking in hockey. CMAJ. 2004;170:15–16; author reply, 6, 8. 136. Denke NJ. Brain injury in sports. J Emerg Nurs. 2008;34:363–364. 137. Gianotti S, Hume PA. Concussion sideline management intervention for rugby union leads to reduced concussion claims. NeuroRehabilitation. 2007;22:181–189. 138. Guilmette TJ, Malia LA, McQuiggan MD. Concussion understanding and management among New England high school football coaches. Brain Inj. 2007;21:1039–1047. 139. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311–319. 140. Valovich McLeod TC, Schwartz C, et al. Sport-related concussion misunderstandings among youth coaches. Clin J Sport Med. 2007;17: 140–142.

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141. Sye G, Sullivan SJ, McCrory P. High school rugby players’ understanding of concussion and return to play guidelines. Br J Sports Med. 2006;40:1003–1005. 142. Theye F, Mueller KA.‘‘Heads up’’: concussions in high school sports. Clin Med Res. 2004;2:165–171. 143. Kashluba S, Paniak C, Blake T, et al. A longitudinal, controlled study of patient complaints following treated mild traumatic brain injury. Arch Clin Neuropsychol. 2004;19:805–816. 144. Gabbe B, Finch CF, Wajswelner H, et al. Does community-level Australian football support injury prevention research? J Sci Med Sport. 2003;6:231–236.

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145. Kaut KP, DePompei R, Kerr J, et al. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention. Clin J Sport Med. 2003;13:213–221. 146. Davidhizar R, Cramer C.‘‘The best thing about the hospitalization was that the nurses kept me well informed.’’ Issues and strategies of client education. Accid Emerg Nurs. 2002;10:149–154. 147. McCrory P. What advice should we give to athletes postconcussion? Br J Sports Med. 2002;36:316–318. 148. Bazarian JJ, Veenema T, Brayer AF, et al. Knowledge of concussion guidelines among practitioners caring for children. Clin Pediatr (Phila). 2001;40:207–212.

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National Athletic Trainers’ Association Position Statement: Management of SportRelated Concussion Kevin M. Guskiewicz*; Scott L. Bruce†; Robert C. Cantu‡; Michael S. Ferrara§; James P. Kelly\; Michael McCrea¶; Margot Putukian#; Tamara C. Valovich McLeod** *University of North Carolina at Chapel Hill, Chapel Hill, NC; †California University of Pennsylvania, California, PA; ‡Emerson Hospital, Concord, MA; §University of Georgia, Athens, GA; \University of Colorado, Denver, CO; ¶Waukesha Memorial Hospital, Waukesha, WI; #Princeton University, Princeton, NJ; **Arizona School of Health Sciences, Mesa, AZ Kevin M. Guskiewicz, PhD, ATC, FACSM; Scott L. Bruce, MS, ATC; Robert C. Cantu, MD, FACSM; Michael S. Ferrara, PhD, ATC; James P. Kelly, MD; Michael McCrea, PhD; Margot Putukian, MD, FACSM; and Tamara C. Valovich McLeod, PhD, ATC, CSCS, contributed to conception and design, acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article. Address correspondence to National Athletic Trainers’ Association, Communications Department, 2952 Stemmons Freeway, Dallas, TX 75247.

port in today’s society is more popular than probably ever imagined. Large numbers of athletes participate in a variety of youth, high school, collegiate, professional, and recreational sports. As sport becomes more of a fixture in the lives of Americans, a burden of responsibility falls on the shoulders of the various organizations, coaches, parents, clinicians, officials, and researchers to provide an environment that minimizes the risk of injury in all sports. For example, the research-based recommendations made for football between 1976 and 1980 resulted in a significant reduction in the incidence of fatalities and nonfatal catastrophic injuries. In 1968, 36 brain and cervical spine fatalities occurred in high school and collegiate football. The number had dropped to zero in 1990 and has averaged about 5 per year since then.1 This decrease was attributed to a variety of factors, including (1) rule changes, which have outlawed spearing and butt blocking, (2) player education about the rule changes and the consequences of not following the rules, (3) implementation of equipment standards, (4) availability of alternative assessment techniques, (5) a marked reduction in physical contact time during practice sessions, (6) a heightened awareness among clinicians of the dangers involved in returning an athlete to competition too early, and (7) the athlete’s awareness of the risks associated with concussion. Research in the area of sport-related concussion has provided the athletic training and medical professions with valuable new knowledge in recent years. Certified athletic trainers, who on average care for 7 concussive injuries per year,2 have been forced to rethink how they manage sport-related concussion. Recurrent concussions to several high-profile athletes, some of whom were forced into retirement as a result, have increased awareness among sports medicine personnel and the general public. Bridging the gap between research and clinical practice

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is the key to reducing the incidence and severity of sportrelated concussion and improving return-to-play decisions. This position statement should provide valuable information and recommendations for certified athletic trainers (ATCs), physicians, and other medical professionals caring for athletes at the youth, high school, collegiate, and elite levels. The following recommendations are derived from the most recent scientific and clinic-based literature on sport-related concussion. The justification for these recommendations is presented in the summary statement following the recommendations. The summary statement is organized into the following sections: ‘‘Defining and Recognizing Concussion,’’ ‘‘Evaluating and Making the Return-to-Play Decision,’’ ‘‘Concussion Assessment Tools,’’ ‘‘When to Refer an Athlete to a Physician After Concussion,’’ ‘‘When to Disqualify an Athlete,’’ ‘‘Special Considerations for the Young Athlete,’’ ‘‘Home Care,’’ and ‘‘Equipment Issues.’’ RECOMMENDATIONS Defining and Recognizing Concussion 1. The ATC should develop a high sensitivity for the various mechanisms and presentations of traumatic brain injury (TBI), including mild, moderate, and severe cerebral concussion, as well as the more severe, but less common, head injuries that can cause damage to the brain stem and other vital centers of the brain. 2. The colloquial term ‘‘ding’’ should not be used to describe a sport-related concussion. This stunned confusional state is a concussion most often reflected by the athlete’s initial confusion, which may disappear within minutes, leaving

no outwardly observable signs and symptoms. Use of the term ‘‘ding’’ generally carries a connotation that diminishes the seriousness of the injury. If an athlete shows concussion-like signs and reports symptoms after a contact to the head, the athlete has, at the very least, sustained a mild concussion and should be treated for a concussion. 3. To detect deteriorating signs and symptoms that may indicate a more serious head injury, the ATC should be able to recognize both the obvious signs (eg, fluctuating levels of consciousness, balance problems, and memory and concentration difficulties) and the more common, selfreported symptoms (eg, headache, ringing in the ears, and nausea). 4. The ATC should play an active role in educating athletes, coaches, and parents about the signs and symptoms associated with concussion, as well as the potential risks of playing while still symptomatic. 5. The ATC should document all pertinent information surrounding the concussive injury, including but not limited to (1) mechanism of injury; (2) initial signs and symptoms; (3) state of consciousness; (4) findings on serial testing of symptoms and neuropsychological function and postural-stability tests (noting any deficits compared with baseline); (5) instructions given to the athlete and/or parent; (6) recommendations provided by the physician; (7) date and time of the athlete’s return to participation; and (8) relevant information on the player’s history of prior concussion and associated recovery pattern(s).3

Evaluating and Making the Return-to-Play Decision 6. Working together, ATCs and team physicians should agree on a philosophy for managing sport-related concussion before the start of the athletic season. Currently 3 approaches are commonly used: (1) grading the concussion at the time of the injury, (2) deferring final grading until all symptoms have resolved, or (3) not using a grading scale but rather focusing attention on the athlete’s recovery via symptoms, neurocognitive testing, and postural-stability testing. After deciding on an approach, the ATC-physician team should be consistent in its use regardless of the athlete, sport, or circumstances surrounding the injury. 7. For athletes playing sports with a high risk of concussion, baseline cognitive and postural-stability testing should be considered. In addition to the concussion injury assessment, the evaluation should also include an assessment of the cervical spine and cranial nerves to identify any cervical spine or vascular intracerebral injuries. 8. The ATC should record the time of the initial injury and document serial assessments of the injured athlete, noting the presence or absence of signs and symptoms of injury. The ATC should monitor vital signs and level of consciousness every 5 minutes after a concussion until the athlete’s condition improves. The athlete should also be monitored over the next few days after the injury for the presence of delayed signs and symptoms and to assess recovery. 9. Concussion severity should be determined by paying close attention to the severity and persistence of all signs and symptoms, including the presence of amnesia (retrograde and anterograde) and loss of consciousness (LOC), as well as headache, concentration problems, dizziness, blurred

vision, and so on. It is recommended that ATCs and physicians consistently use a symptom checklist similar to the one provided in Appendix A. 10. In addition to a thorough clinical evaluation, formal cognitive and postural-stability testing is recommended to assist in objectively determining injury severity and readiness to return to play (RTP). No one test should be used solely to determine recovery or RTP, as concussion presents in many different ways. 11. Once symptom free, the athlete should be reassessed to establish that cognition and postural stability have returned to normal for that player, preferably by comparison with preinjury baseline test results. The RTP decision should be made after an incremental increase in activity with an initial cardiovascular challenge, followed by sport-specific activities that do not place the athlete at risk for concussion. The athlete can be released to full participation as long as no recurrent signs or symptoms are present.

Concussion Assessment Tools 12. Baseline testing on concussion assessment measures is recommended to establish the individual athlete’s ‘‘normal’’ preinjury performance and to provide the most reliable benchmark against which to measure postinjury recovery. Baseline testing also controls for extraneous variables (eg, attention deficit disorder, learning disabilities, age, and education) and for the effects of earlier concussion while also evaluating the possible cumulative effects of recurrent concussions. 13. The use of objective concussion assessment tools will help ATCs more accurately identify deficits caused by injury and postinjury recovery and protect players from the potential risks associated with prematurely returning to competition and sustaining a repeat concussion. The concussion assessment battery should include a combination of tests for cognition, postural stability, and self-reported symptoms known to be affected by concussion. 14. A combination of brief screening tools appropriate for use on the sideline (eg, Standardized Assessment of Concussion [SAC], Balance Error Scoring System [BESS], symptom checklist) and more extensive measures (eg, neuropsychological testing, computerized balance testing) to more precisely evaluate recovery later after injury is recommended. 15. Before instituting a concussion neuropsychological testing battery, the ATC should understand the test’s user requirements, copyright restrictions, and standardized instructions for administration and scoring. All evaluators should be appropriately trained in the standardized instructions for test administration and scoring before embarking on testing or adopting an instrument for clinical use. Ideally, the sports medicine team should include a neuropsychologist, but in reality, many ATCs may not have access to a neuropsychologist for interpretation and consultation, nor the financial resources to support a neuropsychological testing program. In this case, it is recommended that the ATC use screening instruments (eg, SAC, BESS, symptom checklist) that have been developed specifically for use by sports medicine clinicians without extensive

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training in psychometric or standardized testing and that do not require a special license to administer or interpret. 16. Athletic trainers should adopt for clinical use only those neuropsychological and postural stability measures with population-specific normative data, test-retest reliability, clinical validity, and sufficient sensitivity and specificity established in the peer-reviewed literature. These standards provide the basis for how well the test can distinguish between those with and without cerebral dysfunction in order to reduce the possibility of false-positive and false-negative errors, which could lead to clinical decision-making errors. 17. As is the case with all clinical instruments, results from assessment measures to evaluate concussion should be integrated with all aspects of the injury evaluation (eg, physical examination, neurologic evaluation, neuroimaging, and player’s history) for the most effective approach to injury management and RTP decision making. Decisions about an athlete’s RTP should never be based solely on the use of any one test. When to Refer an Athlete to a Physician After Concussion 18. The ATC or team physician should monitor an athlete with a concussion at 5-minute intervals from the time of the injury until the athlete’s condition completely clears or the athlete is referred for further care. Coaches should be informed that in situations when a concussion is suspected but an ATC or physician is not available, their primary role is to ensure that the athlete is immediately seen by an ATC or physician. 19. An athlete with a concussion should be referred to a physician on the day of injury if he or she lost consciousness, experienced amnesia lasting longer than 15 minutes, or meets any of the criteria outlined in Appendix B. 20. A team approach to the assessment of concussion should be taken and include a variety of medical specialists. In addition to family practice or general medicine physician referrals, the ATC should secure other specialist referral sources within the community. For example, neurologists are trained to assist in the management of patients experiencing persistent signs and symptoms, including sleep disturbances. Similarly, a neuropsychologist should be identified as part of the sports medicine team for assisting athletes who require more extensive neuropsychological testing and for interpreting the results of neuropsychological tests. 21. A team approach should be used in making RTP decisions after concussion. This approach should involve input from the ATC, physician, athlete, and any referral sources. The assessment of all information, including the physical examination, imaging studies, objective tests, and exertional tests, should be considered prior to making an RTP decision.

exercises should include sideline jogging followed by sprinting, sit-ups, push-ups, and any sport-specific, noncontact activities (or positions or stances) the athlete might need to perform on returning to participation. Athletes who return on the same day because symptoms resolved quickly (,20 minutes) should be monitored closely after they return to play. They should be repeatedly reevaluated on the sideline after the practice or game and again at 24 and 48 hours postinjury to identify any delayed onset of symptoms. 23. Athletes who experience LOC or amnesia should be disqualified from participating on the day of the injury. 24. The decision to disqualify from further participation on the day of a concussion should be based on a comprehensive physical examination; assessment of self-reported postconcussion signs and symptoms; functional impairments, and the athlete’s past history of concussions. If assessment tools such as the SAC, BESS, neuropsychological test battery, and symptom checklist are not used, a 7-day symptom-free waiting period before returning to participation is recommended. Some circumstances, however, will warrant even more conservative treatment (see recommendation 25). 25. Athletic trainers should be more conservative with athletes who have a history of concussion. Athletes with a history of concussion are at increased risk for sustaining subsequent injuries as well as for slowed recovery of self-reported postconcussion signs and symptoms, cognitive dysfunction, and postural instability after subsequent injuries. In athletes with a history of 3 or more concussions and experiencing slowed recovery, temporary or permanent disqualification from contact sports may be indicated. Special Considerations for the Young Athlete 26. Athletic trainers working with younger (pediatric) athletes should be aware that recovery may take longer than in older athletes. Additionally, these younger athletes are maturing at a relatively fast rate and will likely require more frequent updates of baseline measures compared with older athletes. 27. Many young athletes experience sport-related concussion. Athletic trainers should play an active role in helping to educate young athletes, their parents, and coaches about the dangers of repeated concussions. Continued research into the epidemiology of sport-related concussion in young athletes and prospective investigations to determine the acute and long-term effects of recurrent concussions in younger athletes are warranted. 28. Because damage to the maturing brain of a young athlete can be catastrophic (ie, almost all reported cases of second-impact syndrome are in young athletes), athletes under age 18 years should be managed more conservatively, using stricter RTP guidelines than those used to manage concussion in the more mature athlete.

When to Disqualify an Athlete

Home Care

22. Athletes who are symptomatic at rest and after exertion for at least 20 minutes should be disqualified from returning to participation on the day of the injury. Exertional

29. An athlete with a concussion should be instructed to avoid taking medications except acetaminophen after the injury. Acetaminophen and other medications should be given

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31. 32.

33.

only at the recommendation of a physician. Additionally, the athlete should be instructed to avoid ingesting alcohol, illicit drugs, or other substances that might interfere with cognitive function and neurologic recovery. Any athlete with a concussion should be instructed to rest, but complete bed rest is not recommended. The athlete should resume normal activities of daily living as tolerated while avoiding activities that potentially increase symptoms. Once he or she is symptom free, the athlete may resume a graded program of physical and mental exertion, without contact or risk of concussion, up to the point at which postconcussion signs and symptoms recur. If symptoms appear, the exertion level should be scaled back to allow maximal activity without triggering symptoms. An athlete with a concussion should be instructed to eat a well-balanced diet that is nutritious in both quality and quantity. An athlete should be awakened during the night to check on deteriorating signs and symptoms only if he or she experienced LOC, had prolonged periods of amnesia, or was still experiencing significant symptoms at bedtime. The purpose of the wake-ups is to check for deteriorating signs and symptoms, such as decreased levels of consciousness or increasing headache, which could indicate a more serious head injury or a late-onset complication, such as an intracranial bleed. Oral and written instructions for home care should be given to the athlete and to a responsible adult (eg, parent or roommate) who will observe and supervise the athlete during the acute phase of the concussion while at home or in the dormitory. The ATC and physician should agree on a standard concussion home-instruction form similar to the one presented in Appendix C, and it should be used consistently for all concussions.

Equipment Issues 34. The ATC should enforce the standard use of helmets for protecting against catastrophic head injuries and reducing the severity of cerebral concussions. In sports that require helmet protection (football, lacrosse, ice hockey, baseball/ softball, etc), the ATC should ensure that all equipment meets either the National Operating Committee on Standards for Athletic Equipment (NOCSAE) or American Society for Testing and Materials (ASTM) standards. 35. The ATC should enforce the standard use of mouth guards for protection against dental injuries; however, there is no scientific evidence supporting their use for reducing concussive injury. 36. At this time, the ATC should neither endorse nor discourage the use of soccer headgear for protecting against concussion or the consequences of cumulative, subconcussive impacts to the head. Currently no scientific evidence supports the use of headgear in soccer for reducing concussive injury to the head. DEFINING AND RECOGNIZING CONCUSSION Perhaps the most challenging aspect of managing sport-related concussion is recognizing the injury, especially in athletes with no obvious signs that a concussion has actually occurred. The immediate management of the head-injured athlete

depends on the nature and severity of the injury. Several terms are used to describe this injury, the most global being TBI, which can be classified into 2 types: focal and diffuse. Focal or posttraumatic intracranial mass lesions include subdural hematomas, epidural hematomas, cerebral contusions, and intracerebral hemorrhages and hematomas. These are considered uncommon in sport but are serious injuries; the ATC must be able to detect signs of clinical deterioration or worsening symptoms during serial assessments. Signs and symptoms of these focal vascular emergencies can include LOC, cranial nerve deficits, mental status deterioration, and worsening symptoms. Concern for a significant focal injury should also be raised if these signs or symptoms occur after an initial lucid period in which the athlete seemed normal. Diffuse brain injuries can result in widespread or global disruption of neurologic function and are not usually associated with macroscopically visible brain lesions except in the most severe cases. Most diffuse injuries involve an acceleration-deceleration motion, either within a linear plane or in a rotational direction or both. In these cases, lesions are caused by the brain being shaken within the skull.4,5 The brain is suspended within the skull in cerebrospinal fluid (CSF) and has several dural attachments to bony ridges that make up the inner contours of the skull. With a linear acceleration-deceleration mechanism (side to side or front to back), the brain experiences a sudden momentum change that can result in tissue damage. The key elements of injury mechanism are the velocity of the head before impact, the time over which the force is applied, and the magnitude of the force.4,5 Rotational acceleration-deceleration injuries are believed to be the primary injury mechanism for the most severe diffuse brain injuries. Structural diffuse brain injury (diffuse axonal injury [DAI]) is the most severe type of diffuse injury because axonal disruption occurs, typically resulting in disturbance of cognitive functions, such as concentration and memory. In its most severe form, DAI can disrupt the brain-stem centers responsible for breathing, heart rate, and wakefulness.4,5 Cerebral concussion, which is the focus of this position statement, can best be classified as a mild diffuse injury and is often referred to as mild TBI (MTBI). The injury involves an acceleration-deceleration mechanism in which a blow to the head or the head striking an object results in 1 or more of the following conditions: headache, nausea, vomiting, dizziness, balance problems, feeling ‘‘slowed down,’’ fatigue, trouble sleeping, drowsiness, sensitivity to light or noise, LOC, blurred vision, difficulty remembering, or difficulty concentrating.6 In 1966, the Congress of Neurological Surgeons proposed the following consensus definition of concussion, subsequently endorsed by a variety of medical associations: ‘‘Concussion is a clinical syndrome characterized by immediate and transient impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, etc, due to mechanical forces.’’7 Although the definition received widespread consensus in 1966, more contemporary opinion (as concluded at the First International Conference on Concussion in Sport, Vienna, 20018) was that this definition fails to include many of the predominant clinical features of concussion, such as headache and nausea. It is often reported that there is no universal agreement on the standard definition or nature of concussion; however, agreement does exist on several features that incorporate clinical, pathologic, and biomechanical injury constructs associated with head injury:

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1. Concussion may be caused by a direct blow to the head or elsewhere on the body from an ‘‘impulsive’’ force transmitted to the head. 2. Concussion may cause an immediate and short-lived impairment of neurologic function. 3. Concussion may cause neuropathologic changes; however, the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4. Concussion may cause a gradient of clinical syndromes that may or may not involve LOC. Resolution of the clinical and cognitive symptoms typically follows a sequential course. 5. Concussion is most often associated with normal results on conventional neuroimaging studies.8 Occasionally, players sustain a blow to the head resulting in a stunned confusional state that resolves within minutes. The colloquial term ‘‘ding’’ is often used to describe this initial state. However, the use of this term is not recommended because this stunned confusional state is still considered a concussion resulting in symptoms, although only very short in duration, that should not be dismissed in a cavalier fashion. It is essential that this injury be reevaluated frequently to determine if a more serious injury has occurred, because often the evolving signs and symptoms of a concussion are not evident until several minutes to hours later. Although it is important for the ATC to recognize and eventually classify the concussive injury, it is equally important for the athlete to understand the signs and symptoms of a concussion as well as the potential negative consequences (eg, second-impact syndrome and predisposition to future concussions) of not reporting a concussive injury. Once the athlete has a better understanding of the injury, he or she can provide a more accurate report of the concussion history.

or stretching of tissue, whereas shearing involves a force that moves across the parallel organization of the tissue. Brief, uniform compressive stresses are fairly well tolerated by neural tissue, but tension and shearing stresses are very poorly tolerated.4,9 Neuroimaging of Cerebral Concussion Traditionally, computed tomography (CT) and magnetic resonance imaging (MRI) have been considered useful in identifying certain types of brain lesions; however, they have been of little value in assessing less severe head injuries, such as cerebral concussion, and contributing to the RTP decision. A CT scan is often indicated emergently if a focal injury such as an acute subdural or epidural bleed is suspected; this study easily demonstrates acute blood collection and skull fracture, but an MRI is superior at demonstrating an isodense subacute or chronic subdural hematoma that may be weeks old.10,11 Newer structural MRI modalities, including gradient echo, perfusion, and diffusion-weighted imaging, are more sensitive for structural abnormalities (eg, vascular shearing) compared with other diagnostic imaging techniques.10 Functional imaging technologies (eg, positron emission tomography [PET], singlephoton emission computerized tomography [SPECT], and functional MRI [fMRI]) are also yielding promising early results and may help define concussion recovery.12 Presently, no neuroanatomic or physiologic measurements can be used to determine the severity of a concussion or when complete recovery has occurred in an individual athlete after a concussion. EVALUATING AND MAKING THE RETURN-TO-PLAY DECISION Clinical Evaluation

Mechanisms of Injury A forceful blow to the resting, movable head usually produces maximum brain injury beneath the point of cranial impact (coup injury). A moving head hitting an unyielding object usually produces maximum brain injury opposite the site of cranial impact (contrecoup injury) as the brain shifts within the cranium. When the head is accelerated before impact, the brain lags toward the trailing surface, thus squeezing away the CSF and creating maximal shearing forces at this site. This brain lag actually thickens the layer of CSF under the point of impact, which explains the lack of coup injury in the moving head. Alternatively, when the head is stationary before impact, neither brain lag nor disproportionate distribution of CSF occurs, accounting for the absence of contrecoup injury and the presence of coup injury.4,5 No scientific evidence suggests that one type of injury (coup or contrecoup) is more serious than the other or that symptoms present any differently. Many sport-related concussions are the result of a combined coup-contrecoup mechanism, involving damage to the brain on both the side of initial impact and the opposite side of the brain due to brain lag. Regardless of whether the athlete has sustained a coup, contrecoup, or combined coup-contrecoup injury, the ATC should manage the injury the same. Three types of stresses can be generated by an applied force to injure the brain: compressive, tensile, and shearing. Compression involves a crushing force in which the tissue cannot absorb any additional force or load. Tension involves pulling

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Results from a thorough clinical examination conducted by both the ATC and the physician cannot be overlooked and should be considered very important pieces of the concussion puzzle. These evaluations should include a thorough history (including number and severity of previous head injuries), observation (including pupil responses), palpation, and special tests (including simple tests of memory, concentration, and coordination and a cranial nerve assessment). In many situations, a physician will not be present at the time of the concussion, and the ATC will be forced to act on behalf of the sports medicine team. More formal neuropsychological testing and postural-stability testing should be viewed as adjuncts to the initial clinical and repeat evaluations (see ‘‘Concussion Assessment Tools’’). The ATC-physician team must also consider referral options to specialists such as neurologists, neurosurgeons, neuropsychologists, and neuro-otologists, depending on the injury severity and situation. Referrals for imaging tests such as CT, MRI, or electronystagmography are also options that sometimes can aid in the diagnosis and/or management of sport-related concussion but are typically used only in cases involving LOC, severe amnesia, abnormal physical or neurologic findings, or increasing or intensified symptoms. Determining Injury Severity The definition of concussion is often expanded to include mild, moderate, and severe injuries. Several early grading scales and RTP guidelines early were proposed for classifying

and managing cerebral concussions.6,13–20 None of the scales have been universally accepted or followed with much consistency by the sports medicine community. In addition, most of these classification systems denote the most severe injuries as associated with LOC, which we now know is not always predictive of recovery after a brain injury.21,22 It is important for the ATC and other health care providers to recognize the importance of identifying retrograde amnesia and anterograde amnesia, LOC, and other signs and symptoms present and to manage each episode independently. The ATC must recognize that no 2 concussions are identical and that the resulting symptoms can be very different, depending on the force of the blow to the head, the degree of metabolic dysfunction, the tissue damage and duration of time needed to recover, the number of previous concussions, and the time between injuries. All these factors must be considered when managing an athlete suffering from cerebral concussion.3 The 2 most recognizable signs of a concussion are LOC and amnesia; yet, as previously mentioned, neither is required for an injury to be classified as a concussion. A 2000 study of 1003 concussions sustained by high school and collegiate football players revealed that LOC and amnesia presented infrequently, 9% and 27% of all cases, respectively, whereas other signs and symptoms, such as headache, dizziness, confusion, disorientation, and blurred vision, were much more common.23 After the initial concussion evaluation, the ATC should determine whether the athlete requires more advanced medical intervention on an emergent basis or whether the team physician should be contacted for an RTP decision (Appendix B). It may be helpful if the injury is graded throughout the process, but this grading is likely to be more important for treating subsequent injuries than the current injury. Most grading systems rely heavily on LOC and amnesia as indicators of injury severity. Recent research, however, suggests that these 2 factors, either alone or in combination, are not good predictors of injury severity. A number of authors have documented no association between brief (,1 minute) LOC and abnormalities on neuropsychological testing at 48 hours, raising concern for brief LOC as a predictor of recovery after concussion.8,22,24–27 Studies involving high school and collegiate athletes with concussion revealed no association between (1) LOC and duration of symptoms or (2) LOC and neuropsychological and balance tests at 3, 24, 48, 72, and 96 hours postinjury.21,28,29 In other words, athletes experiencing LOC were similar to athletes without LOC on these same injury-severity markers. With respect to amnesia, the issue is more clouded because findings have been inconsistent. Several studies of nonathletes30–37 suggest that the duration of posttraumatic amnesia correlates with the severity and outcome of severe TBI but not with mild TBI or concussion.38–40 More contemporary studies of athletes with concussion are also clouded. Two unrelated, prospective studies of concussion suggest that the presence of amnesia best correlates with abnormal neuropsychological testing at 48 hours and with the duration and number of other postconcussion signs and symptoms.24,41 However, more recently, investigations of high school and collegiate athletes with concussion revealed no association between (1) amnesia and duration of symptoms or (2) amnesia and neuropsychological and balance tests at 3, 24, 48, 72, and 96 hours postinjury.21,28,29 Of importance in these studies is the significant association between symptom-severity score (within the initial 3 hours postinjury) and the total duration of symptoms (mea-

Table 1. American Academy of Neurology Concussion Grading Scale6 Grade 1 (mild)

Grade 2 (moderate) Grade 3 (severe)

Transient confusion; no LOC*; symptoms and mental status abnormalities resolve ,15 min Transient confusion; no LOC; symptoms and mental status abnormalities last .15 min Any LOC

*LOC indicates loss of consciousness.

sured until asymptomatic). Although these findings suggest that initial symptom severity is probably a better indicator than either LOC or amnesia in predicting length of recovery, amnesia was recently found to predict symptom and neurocognitive deficits at 2 days postinjury.42 More research is needed in this area to help improve clinical decision making. It has been suggested that LOC and amnesia, especially when prolonged, should not be ignored,43,44 but evidence for their usefulness in establishing RTP guidelines is scarce. Loss of consciousness, whether it occurs immediately or after an initially lucid interval, is important in that it may signify a more serious vascular brain injury. Other postconcussion signs and symptoms should be specifically addressed for presence and duration when the ATC is evaluating the athlete. Determining whether a cervical spine injury has occurred is also of major importance because it is often associated with head injury and should not be missed. If the athlete complains of neck pain or has cervical spine tenderness, cervical spine immobilization should be considered. If a cervical spine injury is ruled out and the athlete is taken to the sideline, a thorough clinical examination should follow, including a complete neurologic examination and cognitive evaluation. The ATC must note the time of the injury and then maintain a timed assessment form to follow the athlete’s symptoms and examinations serially. It is often difficult to pay attention to the time that has passed after an injury. Therefore, it is important for one member of the medical team to track time during the evaluation process and record all pertinent information. After an initial evaluation, the clinician must determine whether the injured athlete requires more advanced medical intervention and eventually grade the injury and make an RTP decision that can occur within minutes, hours, days, or weeks of the injury. There are currently 3 approaches to grading sport-related concussion. One approach is to grade the concussion at the time of the injury on the basis of the signs and symptoms present at the time of the concussion and within the first 15 minutes after injury. The American Academy of Neurology Concussion Grading Scale (Table 1)6 has been widely used with this approach. It permits the ATC to grade the injury primarily on the basis of LOC and to provide the athlete, coach, and parent with an estimation of injury severity. A disadvantage to this approach is that many injuries behave differently than expected on initial evaluation, potentially creating more difficulties with the athlete, coach, or parent and making the RTP decision more challenging. Another approach is to grade the concussion on the basis of the presence and overall duration of symptoms. This approach is best addressed using the Cantu Evidence-Based Grading Scale (Table 2),43 which guides the ATC to grade the injury only after all concussion signs and symptoms have resolved. This scale places less emphasis on LOC as a potential predictor of subsequent impairment and additional weight on overall symptom dura-

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Table 2. Cantu Evidence-Based Grading System for Concussion43 Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe)

No LOC*, PTA† ,30 min, PCSS‡ ,24 h LOC ,1 min or PTA $30 min ,24 h or PCSS $24 h ,7 d LOC $1 min or PTA $24 h or PCSS $7 d

*LOC indicates loss of consciousness. †PTA indicates posttraumatic amnesia (anterograde/retrograde). ‡PCSS indicates postconcussion signs and symptoms other than amnesia.

tion.3,43 Finally, a third approach to the grading-scale dilemma is to not use a grading scale but rather focus attention on the athlete’s recovery via symptoms, neuropsychological tests, and postural-stability tests. This line of thinking is that the ATC should not place too much emphasis on the grading system or grade but should instead focus on whether the athlete is symptomatic or symptom free. Once the athlete is asymptomatic, a stepwise progression should be implemented that increases demands over several days. This progression will be different for athletes who are withheld for several weeks compared with those athletes withheld for just a few days. This multitiered approach was summarized and supported by consensus at the 2001 Vienna Conference on Concussion in Sport.8 Making the Return-to-Play Decision The question raised most often regarding the concussion grading and RTP systems is one of practicality in the sport setting. Many clinicians believe that the RTP guidelines are too conservative and, therefore, choose to base decisions on clinical judgment of individual cases rather than on a general recommendation. It has been reported that 30% of all high school and collegiate football players sustaining concussions return to competition on the same day of injury; the remaining 70% average 4 days of rest before returning to participation.23 Many RTP guidelines call for the athlete to be symptom free for at least 7 days before returning to participation after a grade 1 or 2 concussion.6,13,15,17,43,44 Although many clinicians deviate from these recommendations and are more liberal in making RTP decisions, recent studies by Guskiewicz and McCrea et al21,29 suggest that perhaps the 7-day waiting period can minimize the risk of recurrent injury. On average, athletes required 7 days to fully recover after concussion. Same-season repeat injuries typically take place within a short window of time, 7 to 10 days after the first concussion,21 supporting the concept that there may be increased neuronal vulnerability or blood-flow changes during that time, similar to those reported by Giza, Hovda, et al45–47 in animal models. Returning an athlete to participation should follow a progression that begins once the athlete is completely symptom free. All signs and symptoms should be evaluated using a graded symptom scale or checklist (described in ‘‘Concussion Assessment Tools’’) when performing follow-up assessments and should be evaluated both at rest and after exertional maneuvers such as biking, jogging, sit-ups, and push-ups. Baseline measurements of neuropsychological and postural stability are strongly recommended for comparing with postinjury measurements. If these exertional tests do not produce symptoms, either acutely or in delayed fashion, the athlete can then participate in sport-specific skills that allow return to practice but should remain out of any activities that put him or her at risk for recurrent head injury. For the basketball player, this may

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include shooting baskets or participating in walk-throughs, and for the soccer player, this may include dribbling or shooting drills or other sport-specific activities. These restricted and monitored activities should be continued for the first few days after becoming symptom free. The athlete should be monitored periodically throughout and after these sessions to determine if any symptoms develop or increase in intensity. Before returning to full contact participation, the athlete should be reassessed using neuropsychological and postural-stability tests if available. If all scores have returned to baseline or better, return to full participation can be considered after further clinical evaluation. It is strongly recommended that after recurrent injury, especially within-season repeat injuries, the athlete be withheld for an extended period of time (approximately 7 days) after symptoms have resolved. CONCUSSION ASSESSMENT TOOLS Sports medicine clinicians are increasingly using standardized methods to obtain a more objective measurement of postconcussion signs and symptoms, cognitive dysfunction, and postural instability. These methods allow the clinician to quantify the severity of injury and measure the player’s progress over the course of postinjury recovery. An emerging model of sport concussion assessment involves the use of brief screening tools to evaluate postconcussion signs and symptoms, cognitive functioning, and postural stability on the sideline immediately after a concussion and neuropsychological testing to track recovery further out from the time of injury. Ultimately, these tests, when interpreted with the physical examination and other aspects of the injury evaluation, assist the ATC and other sports medicine professionals in the RTP decision-making process. Data from objective measures of cognitive functioning, postural stability, and postconcussion signs and symptoms are most helpful in making a determination about severity of injury and postinjury recovery when preinjury baseline data for an individual athlete are available.3,8,24,29,41 Baseline testing provides an indicator of what is ‘‘normal’’ for that particular athlete while also establishing the most accurate and reliable benchmark against which postinjury results can be compared. It is important to obtain a baseline symptom assessment in addition to baseline cognitive and other ability testing. Without baseline measures, the athlete’s postinjury performance on neuropsychological testing and other concussion assessment measures must be interpreted by comparison with available population normative values, which ideally are based on a large sample of the representative population. Normative data for competitive athletes on conventional (ie, paper-and-pencil) and computerized neuropsychological tests and other concussion assessment measures are now more readily available from large-scale research studies, but baseline data on an individual athlete still provide the greatest clinical accuracy in interpreting postinjury test results. When performing baseline testing, a suitable testing environment eliminates all distractions that could alter the baseline performance and enhances the likelihood that all athletes are providing maximal effort. Most important, all evaluators should be aware of a test’s user requirements and be appropriately trained in the standardized instructions for test administration and scoring before embarking on baseline testing or adopting a concussion testing paradigm for clinical use. Several models exist for implementing baseline testing. Ide-

ally, preseason baseline testing is conducted before athletes are exposed to the risk of concussion during sport participation (eg, before contact drills during football). Some programs choose to conduct baseline testing as part of the preparticipation physical examination process. In this model, stations are established for various testing methods (eg, history collection, symptom assessment, neuropsychological testing, and balance testing), and athletes complete the evaluation sequence after being seen by the attending physician or ATC. This approach has the advantage of testing large groups of athletes in 1 session, while they are already in the mindset of undergoing a preseason physical examination. When preseason examinations are not conducted in a systematic group arrangement, alternative approaches can be considered. In any case, it is helpful to conduct all modules of baseline testing on players in 1 session to limit the complications of scheduling multiple testing times and to keep testing conditions constant for the athletes. One should allow adequate planning time (eg, 3 months) to implement a baseline testing module. Often this equates to conducting baseline testing for fall sports during the spring semester, before school is recessed for the summer. The benefits of interpreting postinjury data for an athlete after a concussion far outweigh the considerable time and human resources dedicated to baseline testing. Collecting histories on individual athletes is also a vital part of baseline testing, especially in establishing whether the athlete has any history of concussion, neurologic disorder, or other remarkable medical conditions. Specifically with respect to concussion, it is important to establish (1) whether the player has any history of concussions and, if so, how many and (2) injury characteristics of previous concussions (eg, LOC, amnesia, symptoms, recovery time, time lost from participation, and medical treatment). For athletes with a history of multiple concussions, it is also important to clarify any apparent pattern of (1) concussions occurring as a result of lighter impacts, (2) concussions occurring closer together in time, (3) a lengthier recovery time with successive concussions, and (4) a less complete recovery with each injury. Documenting a history of attentional disorders, learning disability, or other cognitive development disorders is also critical, especially in interpreting an individual player’s baseline and postinjury performance on neuropsychological testing. If resources do not allow for preseason examinations in all athletes, at least a concerted effort to evaluate those athletes with a previous history of concussion should be made because of the awareness of increased risk for subsequent concussions in this group. Postconcussion Symptom Assessment Self-reported symptoms are among the more obvious and recognizable ways to assess the effects of concussion. Typical self-reported symptoms after a concussion include but are not limited to headache; dizziness; nausea; vomiting; feeling ‘‘in a fog’’; feeling ‘‘slowed down’’; trouble falling asleep; sleeping more than usual; fatigue; drowsiness; sensitivity to light or noise; unsteadiness or loss of balance; feeling ‘‘dinged,’’ dazed, or stunned; seeing stars or flashing lights; ringing in the ears; and double vision.8,26,48 Self-reported symptoms are referenced by many of the concussion grading scales.10,43,44,49 The presence of self-reported symptoms serves as a major contraindication for RTP, and, based on current recommendations, the athlete should be fully symptom free for at least 7 days at rest and during exertion before returning to play.43,44

A number of concussion symptom checklists43,50–52 and scales26,41,48,53 have been used in both research and clinical settings. A symptom checklist that provides a list of concussion-related symptoms allows the athlete to report whether the symptom is present by responding either ‘‘yes’’ (experiencing the symptom) or ‘‘no’’ (not experiencing the symptom). A symptom scale is a summative measure that allows the athlete to describe the extent to which he or she is experiencing the symptom. These instruments commonly incorporate a Likerttype scale that allows the player to rate the severity or frequency of postconcussion symptoms. These scores are then summed to form a composite score that yields a quantitative measure of overall injury severity and a benchmark against which to track postinjury symptom recovery. Initial evidence has been provided for the structural validity of a self-report concussion symptom scale.48 Obtaining a baseline symptom score is helpful to establish any preexisting symptoms attributable to factors other than the head injury (eg, illness, fatigue, or somatization). Serial administration of the symptom checklist is the recommended method of tracking symptom resolution over time (see Appendix A). Mental Status Screening Cognitive screening instruments similar to the physician’s mini mental status examination objectify what is often a subjective impression of cognitive abnormalities. Various methods have been suggested for a systematic survey of mental status and cognitive function in the athlete with a concussion. The SAC was developed to provide sports medicine clinicians with a brief, objective tool for assessing the injured athlete’s mental status during the acute period after concussion (eg, sport sideline, locker room, and clinic).54 The SAC includes measures of orientation, immediate memory, concentration, and delayed recall that sum to 30 points.55 Lower scores on the SAC indicate more severe cognitive impairment. The SAC also includes assessments of strength, sensation, and coordination and a standard neurologic examination but should not replace the clinician’s thorough physical examination or referral for more extensive neuropsychological evaluation when indicated. Information about the occurrence and duration of LOC and amnesia is also recorded on the SAC. Alternate forms of the SAC are available to minimize the practice effects during retesting. The SAC takes about 5 minutes to administer and should be used only after the clinician’s thorough review of the training manual and instructional video on the administration, scoring, and interpretation of the instrument. The SAC has demonstrated reliability29,55,56 and validi29,56,57 ty in detecting mental status changes after a concussion. Recent evidence suggests that a decline of 1 point or more from baseline classified injured and uninjured players with a level of 94% sensitivity and 76% specificity.56 The SAC is also sensitive to detecting more severe neurocognitive changes in injured athletes with LOC or amnesia associated with their concussions.57 The SAC is most useful in the assessment of acute cognitive dysfunction resulting from concussion, with sensitivity and specificity comparable with extensive neuropsychological testing batteries during the initial 2 to 3 days after concussion.29,58,59 As with neuropsychological testing, sensitivity and specificity of the SAC in concussion assessment are maximized when individual baseline test data are available.29,55,56,60

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Postural-Stability Assessment A number of postural-stability tests have been used to assess the effects of concussion in the clinical and laboratory settings. The Romberg and stork stand were basic tests used to assess balance and coordination. Riemann et al61–62 developed the Balance Error Scoring System (BESS) based on existing theories of posturography. The BESS uses 3 stance positions and tests on both a firm and a foam surface with the eyes closed (for a total of 6 trials). The administration and scoring procedures are found in several publications.61–63 The BESS has established good test-retest reliability and good concurrent validity when compared with laboratory forceplate measures52,62 and significant group differences, with an increased number of errors for days 1, 3, and 5 postinjury when compared with controls.52 Thus, the BESS can be used as a clinical measure in identifying balance impairment that could indicate a neurologic deficit. The NeuroCom Smart Balance Master System (NeuroCom International, Clackamas, OR) is a forceplate system that measures vertical ground reaction forces produced by the body’s center of gravity moving around a fixed base of support. The Sensory Organization Test (SOT, NeuroCom International) is designed to disrupt various sensory systems, including the visual, somatosensory, and vestibular systems. The SOT consists of 6 conditions with 3 trials per condition, for a total of 18 trials, with each trial lasting 20 seconds. The complete administration has been described previously.52,64 The SOT has produced significant findings related to the assessment of concussion recovery. In a sample of 36 athletes with concussion, the mean stability (composite score) and vestibular and visual ratios demonstrated deficits for up to 5 days postinjury.52 The greatest deficits were seen 24 hours postinjury, and the athletes with concussion demonstrated a gradual recovery during the 5-day period to within 6% of baseline scores. These results were confirmed by Peterson et al,65 who found that these deficits continued for up to 10 days after concussion. These findings reveal a sensory interaction problem from the effects of concussion with measurable changes in overall postural stability. Neuropsychological Testing Neuropsychological testing has historically been used to evaluate various cognitive domains known to be preferentially susceptible to the effects of concussion and TBI. In recent years, neuropsychological testing to evaluate the effects of sport-related concussion has gained much attention in the sport concussion literature.20,21,26,29,48,52,58,59,65–69 The work of Barth et al,70 who studied more than 2000 collegiate football players from 10 universities, was the first project to institute baseline neuropsychological testing. Similar programs are now commonplace among many collegiate and professional teams, and interest is growing at the high school level. Several recent studies have supported the use of neuropsychological testing as a valuable tool to evaluate the cognitive effects and recovery after sport-related concussion,24,28,29,41,42,50–52,57,65,66,71–75 but its feasibility for sideline use is not likely realistic. As is the case with other concussion assessment tools, baseline neuropsychological testing is recommended, when possible, to establish a normative level of neurocognitive functioning for individual athletes. 24,28,29,41,50 –52,57–59,66,69,73–75 Baseline neuropsychological testing typically takes 20 to 30 minutes per athlete.

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Before implementing a neuropsychological testing program, the ATC must consider several issues, including test-specific training requirements and methodologic issues, the practicality of baseline testing, the reliability and validity of individual tests comprising the test battery, and the protocol for interpretation of the postinjury test results. Barr76 provided an excellent review on the methodologic and professional issues associated with neuropsychological testing in sport concussion assessment. Most states require advanced training and licensure to purchase and use neuropsychological tests for clinical purposes. Neuropsychological tests are also copyright protected to prevent inappropriate distribution or use by unqualified professionals. At present, these requirements necessitate that a licensed psychologist, preferably one Board certified in clinical neuropsychology or with clinical experience in the evaluation of sport-related concussion, oversee and supervise the clinical application of neuropsychological testing for sport concussion assessment. These factors likely restrict how widely neuropsychological testing can be used to assess sport-related concussion, especially at the high school level and in rural areas where neuropsychologists are not readily available for consultation. Neuropsychologists, ATCs, and sports medicine clinicians are faced with the challenge of designing a model that jointly upholds the testing standards of neuropsychology and meets the clinical needs of the sports medicine community without undue burden. The cost of neuropsychological testing, either conventional or computerized, is also a factor in how widely this method can be implemented, especially at the high school level. Consultation fees for the neuropsychologist can be considerable if work is not done on a pro bono basis, and some computerized testing companies charge a consulting fee for interpreting postinjury test results by telephone. Although no clear indications exist as to which are the best individual neuropsychological tests to evaluate sport concussion, the use of multiple instruments as a ‘‘test battery’’ offers clinicians greater potential for recognizing any cognitive deficits incurred from the injury. A number of neuropsychological tests and test batteries have been used to assess sport-related concussion. Table 3 provides a brief description of the paperand-pencil neuropsychological tests commonly used by neuropsychologists in the assessment of sport concussion. Sport concussion batteries should include measures of cognitive abilities most susceptible to change after concussion, including attention and concentration, cognitive processing (speed and efficiency), learning and memory, working memory, executive functioning, and verbal fluency. Tests of attention and concentration50,52,74,77 and memory functioning41 have been reported as the most sensitive to the acute effects of concussion. The athlete’s age, sex, primary language, and level of education should be considered when selecting a test battery.68 Computerized Neuropsychological Tests. Recently, a number of computerized neuropsychological testing programs have been designed for the assessment of athletes after concussion. The Automated Neuropsychological Assessment Metrics (ANAM), CogSport, Concussion Resolution Index, and Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) are all currently available and have shown promise for reliable and valid concussion assessment (Table 4).24,41,51,53,66,71,72,75,78–84 The primary advantages to computerized testing are the ease of administration, ability to baseline test a large number of athletes in a short period of time, and multiple forms used within the testing paradigm to reduce the

Table 3. Common Neuropsychological Tests Used in Sport Concussion Assessment Neuropsychological Test Controlled Oral Word Association Test Hopkins Verbal Learning Test Trail Making: Parts A and B

Wechsler Letter Number Sequencing Test Wechsler Digit Span: Digits Forward and Digits Backward Wechsler Digit Symbol Test Symbol Digit Modalities Test Paced Auditory Serial Addition Test Stroop Color Word Test

Cognitive Domain Verbal fluency Verbal learning, immediate and delayed memory Visual scanning, attention, information processing speed, psychomotor speed Verbal working memory Attention, concentration Psychomotor speed, attention, concentration Psychomotor speed, attention, concentration Attention, concentration Attention, information processing speed

practice effects. Collie et al71 summarized the advantage and disadvantages of computerized versus traditional paper-andpencil testing. As outlined, in the case of conventional neuropsychological testing, several of the same challenges must be addressed before computerized testing becomes a widely used method of sport concussion assessment. Issues requiring further consideration include demonstrated test reliability; validity, sensitivity, and specificity in the peer-reviewed literature; required user training and qualifications; the necessary role of the licensed psychologist for clinical interpretation of postinjury test results; hardware and software issues inherent to computerized testing; and user costs.71 Progress is being made on many of these issues, but further clinical research is required

to provide clinicians with the most effective neuropsychological assessment tools and maintain the testing standards of neuropsychology. Neuropsychological Testing Methods. Neuropsychological testing is not a tool that should be used to diagnose the injury (ie, concussion); however, it can be very useful in measuring recovery once it has been determined that a concussion has occurred. The point(s) at which postinjury neuropsychological testing should occur has been a topic of debate. A variety of testing formats has been used to evaluate short-term recovery from concussion.24,41,50,73,75,82 Two approaches are most common. The first incorporates neuropsychological testing only after the injured player reports that his or her symptoms are completely gone. This approach is based on the conceptual foundation that an athlete should not participate while symptomatic, regardless of neuropsychological test performance. Unnecessary serial neuropsychological testing, in addition to being burdensome and costly to the athlete and medical staff, also introduces practice effects that may confound the interpretation of performance in subsequent postinjury testing sessions.85 The second approach incorporates neuropsychological testing at fixed time points (eg, postinjury day 1, day 7, and so on) to track postinjury recovery. This approach is often appropriate for prospective research protocols but is unnecessary in a clinical setting when the player is still symptomatic and will be withheld from competition regardless of the neuropsychological test results. In this model, serial testing can be used until neuropsychological testing returns to normal, preinjury levels and the player is completely symptom free. Measuring ‘‘recovery’’ on neuropsychological tests and other clinical instruments is often a complex statistical matter, further complicated by practice effects and other psychometric dynamics affected by serial testing, even when preinjury baseline data are available for individual athletes. The use of statistical models that empirically identify meaningful change while controlling for practice effects on serial testing may provide the clinician with the most precise benchmark in deter-

Table 4. Computerized Neuropsychological Tests Neuropsychological Test

Developer (Contact Information)

Cognitive Domains

Automated Neuropsychological Assessment Metrics (ANAM)

National Rehabilitation Hospital Assistive Technology and Neuroscience Center, Washington, DC84 (jsb2@mhg.edu)

Simple Reaction Metrics Sternberg Memory Math Processing Continuous Performance Matching to Sample Spatial Processing Code Substitution

CogSport

CogState Ltd, Victoria, Australia (www.cogsport.com)

Simple Reaction Time Complex Reaction Time One-Back Continuous Learning

Concussion Resolution Index

HeadMinder Inc, New York, NY (www.headminder.com)

Reaction Time Cued Reaction Time Visual Recognition 1 Visual Recognition 2 Animal Decoding Symbol Scanning

Immediate Postconcussion Assessment and Cognitive Testing (ImPACT)

University of Pittsburgh Medical Center, Pittsburgh, PA (www.impacttest.com)

Verbal Memory Visual Memory Information Processing Speed Reaction Time Impulse Control

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Table 5. Factors Influencing Neuropsychological Test Performance68* Previous concussions Educational background Preinjury level of cognitive functioning Cultural background Age Test anxiety Distractions Sleep deprivation Medications, alcohol, or drugs Psychiatric disorders Learning disability Attention deficit/hyperactivity Certain medical conditions Primary language other than English Previous neuropsychological testing *Reprinted with permission of Grindel SH, Lovell MR, Collins MW. The assessment of sport-related concussion: the evidence behind neuropsychological testing and management. Clin J Sport Med. 2001; 11: 134–143.

mining postinjury recovery, above and beyond the simple conclusion that the player is ‘‘back to baseline.’’ The complexity of this analysis is the basis for the neuropsychologist overseeing the clinical interpretation of test data to determine injury severity and recovery. Further research is required to clarify the guidelines for determining and tracking recovery on specific measures after concussion. The clinician should also be aware that any concussion assessment tool, either brief screening instruments or more extensive neuropsychological testing, comes with some degree of risk for false negatives (eg, a player performs within what would be considered the normal range on the measure before actually reaching a complete clinical recovery after concussion). Therefore, test results should always be interpreted in the context of all clinical information, including the player’s medical history. Also, caution should be exercised in neuropsychological test interpretation when preinjury baseline data do not exist. Numerous factors apart from the direct effects of concussion can influence test performance (Table 5). WHEN TO REFER AN ATHLETE TO A PHYSICIAN AFTER CONCUSSION Although most sport-related concussions are considered mild head injuries, the potential exists for complications and life-threatening injuries. Each ATC should be concerned about the potential for the condition of an athlete with a concussion to deteriorate. This downward trend can occur immediately (minutes to hours) or over several days after the injury. As discussed earlier, the spectrum of sport-related head injuries includes more threatening injuries, such as epidural and subdural hematomas and second-impact syndrome. Postconcussion syndrome, however, is a more likely consequence of a sport-related concussion. Not every sport-related concussion warrants immediate physician referral, but ATCs must be able to recognize those injuries that require further attention and provide an appropriate referral for advanced care, which may include neuroimaging. Serial assessments and physician follow-up are important parts of the evaluation of the athlete with a concussion. Referrals should be made to medical personnel with experience managing sport-related concussion. The ATC should monitor vital signs and level of consciousness every 5

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minutes after a concussion until the athlete’s condition stabilizes and improves. The athlete should also be monitored over the next few hours and days after the injury for delayed signs and symptoms and to assess recovery. Appendix B outlines scenarios that warrant physician referral or, in many cases, transport to the nearest hospital emergency department. WHEN TO DISQUALIFY AN ATHLETE Return to participation after severe or repetitive concussive injury should be considered only if the athlete is completely symptom free and has a normal neurologic examination, normal neuropsychological and postural-stability examinations, and, if obtained, normal neuroimaging studies (ie, MRI with gradient echo). It may not be practical or even possible to use all these assessments in all athletes or young children, but a cautious clinical judgment should take into account all evaluation options. Each injured athlete should be considered individually, with consideration for factors including age, level of participation, nature of the sport (high risk versus low risk), and concussion history. Standardized neuropsychological testing, which typically assesses orientation, immediate and delayed memory recall, and concentration may assist the ATC and physician in determining when to disqualify an athlete from further participation.60 Balance testing may provide additional information to assist the clinician in the decision-making process of whether to disqualify an individual after a concussion.52 When to disqualify the athlete is one of the most important decisions facing the ATC and team physician when dealing with an athlete suffering from a concussion. This includes not only when to disqualify for a single practice or event but also when to disqualify for the season or for a career. Disqualifying for the Game or Practice The decision to disqualify an individual from further participation on the day of the concussive episode is based on the sideline evaluation, the symptoms the athlete is experiencing, the severity of the apparent symptoms, and the patient’s past history.86 The literature is clear: any episode involving LOC or persistent symptoms related to concussion (headache, dizziness, amnesia, and so on), regardless of how mild and transient, warrants disqualification for the remainder of that day’s activities.8,9,13,19,43,60,87 More recent studies of high school and collegiate athletes underscore the importance of ensuring that the athlete is symptom free before returning to participation on the same day; even when the player is symptom free within 15 to 20 minutes after the concussive episode, he or she may still demonstrate delayed symptoms or depressed neurocognitive levels. Lovell et al88 found significant memory deficits 36 hours postinjury in athletes who were symptom free within 15 minutes of a mild concussion. Guskiewicz et al21 found that 33% (10/30) of the players with concussion who returned on the same day of injury experienced delayed onset of symptoms at 3 hours postinjury, as compared with only 12.6% (20/ 158) of those who did not return to play on the same day of injury. Although more prospective work is needed in this area, these studies raise questions as to whether the RTP criteria for grade 1 (mild) concussions are conservative enough.

Disqualifying for the Season Cantu43

Guidelines from and the American Academy of Neurology6 both recommend termination of the season after the third concussion within the same season. The decision is more difficult if one of the injuries was more severe or was a severe injury resulting from a minimal blow, suggesting that the athlete’s brain may be at particular risk for recurrent injury. In addition, because many athletes participate in year-round activities, once they are disqualified for the ‘‘season,’’ it may be difficult to determine at what point they can resume contact play. Other issues without clear-cut answers in the literature are when to disqualify an athlete who has not been rendered unconscious and whose symptoms cleared rapidly or one who suffered multiple mild to moderate concussions throughout the career and whether youth athletes should be treated differently for initial and recurrent concussive injuries. Disqualifying for the Career When to disqualify an athlete for a career is a more difficult question to answer. The duration of symptoms may be a better criterion as to when to disqualify an athlete for the season or longer. Merril Hoge, Eric Lindros, Chris Miller, Al Toon, and Steve Young provide highly publicized cases of athletes sustaining multiple concussions with recurrent or postconcussion signs and symptoms that lasted for lengthy periods of time.43 Once an athlete has suffered a concussion, he or she is at increased risk for subsequent head injuries.21,43,86 Guskiewicz et al21,23 found that collegiate athletes had a 3-fold greater risk of suffering a concussion if they had sustained 3 or more previous concussions in a 7-year period and that players with 2 or more previous concussions required a longer time for total symptom resolution after subsequent injuries.21 Players also had a 3-fold greater risk for subsequent concussions in the same season,23 whereas recurrent, in-season injuries occurred within 10 days of the initial injury 92% of the time.21 In a similar study of high school athletes, Collins et al82 found that athletes with 3 or more prior concussions were at an increased risk of experiencing LOC (8-fold greater risk), anterograde amnesia (5.5-fold greater risk), and confusion (5.1-fold greater risk) after subsequent concussion. Despite the increasing body of literature on this topic, debate still surrounds the question of how many concussions are enough to recommend ending the player’s career. Some research suggests that the magic number may be 3 concussions in a career.21,23,82 Although these findings are important, they should be carefully interpreted because concussions present in varying degrees of severity, and all athletes do not respond in the same way to concussive insults. Most important is that these data provide evidence for exercising caution when managing younger athletes with concussion and athletes with a history of previous concussions. SPECIAL CONSIDERATIONS FOR THE YOUNG ATHLETE Many epidemiologic studies on concussion have focused on professional or collegiate athletes. However, this focus seems to now be shifting to the high school level and even to youth sports. Special consideration must be given to the young athlete. The fact that the brain of the young athlete is still developing cannot be ignored, and the effect of concussion on the developing brain is still not entirely understood. Even sub-

tle damage may lead to deficits in learning that adversely influence development. Therefore, it has been suggested that pediatric athletes suffering a concussion should be restricted from further participation for the day and that additional consideration should be given as to when to return these individuals to activity.46 Recent epidemiologic investigations of head-injury rates in high school athletes have shown that 13.3% of all reported injuries in high school football affect the head and neck, whereas the numbers in other sports range from 1.9% to 9.5% in baseball and wrestling, respectively.89 Guskiewicz et al23 prospectively examined concussion incidence in high school and collegiate football players and found that the greatest incidence was at the high school level (5.6%), compared with the National Collegiate Athletic Association Division I (4.4%), Division II (4.5%), and Division III (5.5%). Authors who have tracked symptoms and neuropsychological function after concussion suggest that age-related differences exist between high school and collegiate athletes with regard to recovery. Lovell et al41 reported that the duration of on-field mental status changes in high school athletes, such as retrograde amnesia and posttraumatic confusion, was related to the presence of memory impairment at 36 hours, 4 days, and 7 days postinjury as well as slower resolution of selfreported symptoms. These findings further emphasize the need to collect these on-field measures after concussion and to use the information wisely in making RTP decisions, especially when dealing with younger athletes. Field et al90 found that high school athletes who sustained a concussion demonstrated prolonged memory dysfunction compared with collegiate athletes who sustained a concussion. The high school athletes performed significantly worse on select tests of memory than age-matched control subjects at 7 days postinjury when compared with collegiate athletes and their age-matched control subjects. We hope these important studies and others will eventually lead to more specific guidelines for managing concussions in high school athletes. Very few investigators have studied sport-related injuries in the youth population, and even fewer focused specifically on sport-related concussion. One group91 reported that 15% of the children (mean 5 8.34 6 5.31 years) who were admitted to hospitals after MTBI suffered from a sport-related mechanism of injury. Another group92 found that sport-related head injury accounted for 3% of all sport-related injuries and 24% of all serious head injuries treated in an emergency department. Additionally, sport-related concussion represented a substantial percentage of all head injuries in children under the age of 10 years (18.2%) and 10- to 14-year-old (53.4%) and 15- to 19year-old (42.9%) populations.92 Thus, sport-related head injury has a relatively high incidence rate and is a significant public health concern in youth athletes, not just participants at higher competitive levels. Although no prospective investigations in younger athletes (younger than 15 years old) have been undertaken regarding symptom resolution and cognitive or postural-stability recovery, Valovich McLeod et al93 recently determined the reliability and validity of brief concussion assessment tools in a group of healthy young athletes (9–14 years old). The SAC is valid within 48 hours of injury and reliable for testing of youths above age 5 years, but younger athletes score slightly below high school and collegiate athletes.55 This issue is remedied, however, if preseason baseline testing is conducted for all players and a preinjury baseline score established for each

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athlete against which changes resulting from concussion can be detected and other factors that affect test performance can be controlled. Users of standardized clinical tools should be aware of the effects of age and education on cognitive test performance and make certain to select the appropriate normative group for comparison when testing an injured athlete at a specific competitive level. Uncertainties about the effects of concussion on young children warrant further study. HOME CARE Once the athlete has been thoroughly evaluated and determined to have sustained a concussion, a comprehensive medical management plan should be implemented. This plan should include frequent medical evaluations and observations, continued monitoring of postconcussion signs and symptoms, and postinjury cognitive and balance testing. If symptoms persist or worsen or the level of consciousness deteriorates at all after a concussion, neuroimaging should be performed. Although scientific evidence for the evaluation and resolution of the concussion is ample, specific management advice to be given to the athlete on leaving the athletic training room is lacking.94 Athletic trainers and hospital emergency rooms have created various home instruction forms, but minimal scientific evidence supports these instructions. However, despite these limitations, a concussion instruction form (Appendix C) should be given to the athlete and a responsible adult who will have direct contact with the athlete for the initial 24 hours after the injury. This form helps the companion to know what signs and symptoms to watch for and provides useful recommendations on follow-up care. Medications At this time, the clinician has no evidence-based pharmacologic treatment options for an athlete with a concussion.95 Most pharmacologic studies have been performed in severely head-injured patients. It has been suggested that athletes with concussion avoid medications containing aspirin or nonsteroidal anti-inflammatories, which decrease platelet function and potentially increase intracranial bleeding, mask the severity and duration of symptoms, and possibly lead to a more severe injury. It is also recommended that acetaminophen (Tylenol, McNeil Consumer & Specialty Pharmaceuticals, Fort Washington, PA) be used sparingly in the treatment of headachelike symptoms in the athlete with a concussion. Other substances to avoid during the acute postconcussion period include those that adversely affect central nervous function, in particular alcohol and narcotics. Wake-Ups and Rest Once it has been determined that a concussion has been sustained, a decision must be made as to whether the athlete can return home or should be considered for overnight observation or admission to the hospital. For more severe injuries, the athlete should be evaluated by the team physician or emergency room physician if the team physician is not available. If the athlete is allowed to return home or to the dormitory room, the ATC should counsel a friend, teammate, or parent to closely monitor the athlete. Traditionally, part of these instructions included a recommendation to wake up the athlete every 3 to 4 hours during the night to evaluate changes in

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symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. This recommendation has raised some debate about unnecessary wake-ups that disrupt the athlete’s sleep pattern and may increase symptoms the next day because of the combined effects of the injury and sleep deprivation. It is further suggested that the concussed athlete have a teammate or friend stay during the night and that the athlete not be left alone. No documented evidence suggests what severity of injury requires this treatment. However, a good rule to use is if the athlete experienced LOC, had prolonged periods of amnesia, or is still experiencing significant symptoms, he or she should be awakened during the night. Both oral and written instructions should be given to both the athlete and the caregiver regarding waking.96 The use of written and oral instructions increases the compliance to 55% for purposeful waking in the middle of the night. In the treatment of concussion, complete bed rest was ineffective in decreasing postconcussion signs and symptoms.97 The athlete should avoid activities that may increase symptoms (eg, staying up late studying and physical education class) and should resume normal activities of daily living, such as attending class and driving, once symptoms begin to resolve or decrease in severity. As previously discussed, a graded test of exertion should be used to determine the athlete’s ability to safely return to full activity. Diet Evidence is limited to support the best type of diet for aiding in the recovery process after a concussion. A cascade of neurochemical, ionic, and metabolic changes occur after brain injury.47 Furthermore, some areas of the brain demonstrate glycolytic increases and go into a state of metabolic depression as a result of decreases in both glucose and oxidative metabolism with a reduction in cerebral blood flow. Severely braininjured subjects ate larger meals and increased their daily caloric intake when compared with controls.98 Although limited information is available regarding the recommended diet for the management of concussion, it is well accepted that athletes should be instructed to avoid alcohol, illicit drugs, and central nervous system medications that may interfere with cognitive function. A normal, well-balanced diet should be maintained to provide the needed nutrients to aid in the recovery process from the injury. EQUIPMENT ISSUES Helmets and Headgear Although wearing a helmet will not prevent all head injuries, a properly fitted helmet for certain sports reduces the risk of such injuries. A poorly fitted helmet is limited in the amount of protection it can provide, and the ATC must play a role in enforcing the proper fitting and use of the helmet. Protective sport helmets are designed primarily to prevent catastrophic injuries (ie, skull fractures and intracranial hematomas) and are not designed to prevent concussions. A helmet that protects the head from a skull fracture does not adequately prevent the rotational and shearing forces that lead to many concussions.99 The National Collegiate Athletic Association requires helmets be worn for the following sports: baseball, field hockey (goalkeepers only), football, ice hockey, women’s lacrosse (goalkeepers only), men’s lacrosse, and skiing. Helmets are

also recommended for recreational sports such as bicycling, skiing, mountain biking, roller and inline skating, and speed skating. Headgear standards are established and tested by the National Operating Committee on Standards for Athletic Equipment and the American Society for Testing and Materials.99 Efforts to establish and verify standards continue to be tested and refined, but rarely are the forces and conditions experienced on the field by the athletes duplicated. In addition to direction, speed, and amount of the forces delivered and received by the athlete, conditions not controlled in the testing process include weather conditions, changes in external temperatures and temperatures inside the helmet, humidity levels, coefficient of friction for the surfaces of the equipment and ground, and density of the equipment and ground. However, equipment that does meet the standards is effective in reducing head injuries.99 More recently, the issue of headgear for soccer players has received much attention. Although several soccer organizations and governing bodies have approved the use of protective headbands in soccer, no published, peer-reviewed studies support their use. Recommendations supporting the use and performance of headgear for soccer are limited by a critical gap in biomechanical information about head impacts in the sport of soccer. Without data linking the severity and type of impacts and the clinical sequelae of single and repeated impacts, specifications for soccer headgear cannot be established scientifically. These types of headgear may reduce the ‘‘sting’’ of a head impact, yet they likely do not meet other sports headgear performance standards. This type of headgear may actually increase the incidence of injury. Players wearing headgear may have the false impression that the headgear will protect them during more aggressive play and thereby subject themselves to even more severe impacts that may not be attenuated by the headgear. Mouth Guards The wearing of a mouth guard is thought by some to provide additional protection for the athlete against concussion by either reducing the risk of injury or reducing the severity of the injury itself.100 Mouth guards aid in the separation between the head of the condyle of the mandible and the base of the skull. It is thought that wearing an improperly fitted mouth guard or none at all increases this contact point. This theory, which is based on Newtonian laws of physics, suggests that the increased separation between 2 adjacent structures increases the time to contact, thus decreasing the amount of contact and decreasing the trauma done to the brain.100 However, no biomechanical studies support the theory that the increased separation results in less force being delivered to the brain. High school football and National Collegiate Athletic Association football rules mandate the wearing of a mouth guard, but the National Football League rulebook does not require players to wear a mouth guard. The National Collegiate Athletic Association requires mouth guards to be worn by all athletes in football, field hockey, ice hockey, and lacrosse. Researchers 101,102 have found no advantage in wearing a custom-made mouth guard over a boil-and-bite mouth guard to reduce the rise of cerebral concussion in athletes. However, ATCs and coaches should mandate the regular use of mouth guards because a properly fitted mouth guard, with no alterations such as cutting off the back part, is of great value in

protecting the teeth and preventing fractures and avulsions that could require many years of expensive dental care. ACKNOWLEDGMENTS We gratefully acknowledge the efforts of Kent Scriber, PhD, ATC; Scott Anderson, MS, ATC; Michael Collins, PhD; Vito A. Perriello, Jr, MD, PhD; Karen Johnston, MD, PhD; and the Pronouncements Committee in the preparation of this document.

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1 or ‘‘ding’’ concussions in high school athletes. Am J Sports Med. 2004; 32:47–54. Powell JW, Barber-Foss KD. Injury patterns in selected high school sports: a review of the 1995–1997 seasons. J Athl Train. 1999;34:277– 284. Field M, Collins MW, Lovell MR. Does age play a role in recovery from sports related concussion? A comparison of high school and collegiate athletes. Am J Pediatr. 2003;142:546–553. Adams J, Frumiento C, Shatney-Leach L, Vane DW. Mandatory admission after isolated mild closed head injury in children: is it necessary? J Pediatr Surg. 2001;36:119–121. Kelly KD, Lissel HL, Rowe BH, Vincenten JA, Voaklander DC. Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med. 2001;11:77–81. Valovich McLeod TC, Perrin DH, Guskiewicz KM, Diamond R, Shultz SJ, Gansneder BM. Serial administration of clinical concussion assessments and learning effects in healthy young athletes. Clin J Sport Med. In press. McCrory P. What advice should we give to athletes postconcussion? Br J Sports Med. 2002;36:316–318. McCrory P. New treatments for concussion: the next millennium beckons. Clin J Sport Med. 2001;11:190–193. de Louw A, Twijnstra A, Leffers P. Lack of uniformity and low compliance concerning wake-up advice following head trauma. Ned Tijdschr Geneeskd. 1994;138:2197–2199. de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002;73: 167–172. Henson MB, De Castro JM, Stringer AY, Johnson C. Food intake by brain-injury humans who are in the chronic phase of recovery. Brain Inj. 1993;7:169–178. Halstead DP. Performance testing updates in head, face, and eye protection. J Athl Train. 2001;36:322–327. Winters JE Sr. Commentary: role of properly fitted mouthguards in prevention of sport-related concussion. J Athl Train. 2001;36:339– 341. Labella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc. 2002;34:41–44. Wisniewski JF, Guskiewicz KM, Trope M, Sigurdsson A. Incidence of cerebral concussions associated with type of mouthguard used in college football. Dent Traumatol. 2004;20:143–149.

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Appendix A. Graded Symptom Checklist

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• Number 3 • September 2004

Appendix B. Physician Referral Checklist Day-of-injury referral 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Loss of consciousness on the field Amnesia lasting longer than 15 min Deterioration of neurologic function* Decreasing level of consciousness* Decrease or irregularity in respirations* Decrease or irregularity in pulse* Increase in blood pressure Unequal, dilated, or unreactive pupils* Cranial nerve deficits Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding* 11. Mental status changes: lethargy, difficulty maintaining arousal, confusion, or agitation* 12. Seizure activity* 13. Vomiting

14. 15. 16. 17. 18. 19.

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 Postconcussion symptoms that worsen Additional postconcussion symptoms as compared with those on the field 20. Athlete is still symptomatic at the end of the game (especially at high school level)

Delayed referral (after the day of injury) 1. 2. 3. 4.

Any of the findings in the day-of-injury referral category Postconcussion symptoms worsen or do not improve over time Increase in the number of postconcussion symptoms reported Postconcussion symptoms begin to interfere with the athlete’s daily activities (ie, sleep disturbances or cognitive difficulties)

*Requires that the athlete be transported immediately to the nearest emergency department.

Appendix C. Concussion Home Instructions I believe that

sustained a concussion on

. To make sure

he/she recovers, please follow the following important recommendations:

1. Please remind

to report to the athletic training room tomorrow at

for a follow-

up evaluation.

2. Please review the items outlined on the enclosed Physician Referral Checklist. If any of these problems develop prior to his/her visit, please call

or contact the local emergency medical system or your family

physician. Otherwise, you can follow the instructions outlined below. It is OK to:

There is NO need to:

Do NOT:

● Use acetaminophen (Tylenol) for headaches ● Use ice pack on head and neck as needed for comfort ● Eat a light diet ● Return to school ● Go to sleep ● Rest (no strenuous activity or sports)

● ● ● ●

● Drink alcohol ● Eat spicy foods

Check eyes with flashlight Wake up every hour Test reflexes Stay in bed

Specific recommendations:

Recommendations provided to:

Recommendations provided by:

Date:

Time:

Please feel free to contact me if you have any questions. I can be reached at:

Signature:

Date:

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SPECIAL COMMUNICATIONS Team Physician Consensus Statement

Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement*

DEFINITION

SUMMARY

Concussion or mild traumatic brain injury (MTBI) is a pathophysiological process affecting the brain induced by direct or indirect biomechanical forces. Common features include:

This document provides an overview of select medical issues that are important to team physicians who are responsible for athletes with concussion. It is not intended as a standard of care, and should not be interpreted as such. This document is only a guide, and as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare professional. Individual treatment will turn on the specific facts and circumstances presented to the physician. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.

• Rapid onset of usually short-lived neurological impairment, which typically resolves spontaneously.

• Acute clinical symptoms that usually reflect a functional disturbance rather than structural injury.

• A range of clinical symptoms that may or may not involve loss of consciousness (LOC).

• Neuroimaging studies that are typically normal.

GOAL The goal is to assist the team physician in providing optimal medical care for the athlete with concussion. To accomplish this goal, the team physician should have knowledge of and be involved with:

• • • • • • • • •

Epidemiology Pathophysiology Game-day evaluation and treatment Post–game-day evaluation and treatment Diagnostic imaging Management principles Return-to-play Complications of concussion Prevention

EXPERT PANEL Stanley A. Herring, M.D., Chair, Seattle, Washington John A. Bergfeld, M.D., Cleveland, Ohio Arthur Boland, M.D., Boston, Massachusetts Lori A. Boyajian-O’Neill, D.O., Kansas City, Missouri Robert C. Cantu, M.D., Concord, Massachusetts Elliott Hershman, M.D., New York, New York Peter Indelicato, M.D., Gainesville, Florida Rebecca Jaffe, M.D., Wilmington, Delaware W. Ben Kibler, M.D., Lexington, Kentucky Douglas B. McKeag, M.D., Indianapolis, Indiana Robert Pallay, M.D., Hillsborough, New Jersey Margot Putukian, M.D., Princeton, New Jersey

*Editor’s Note: The Team Physician Consensus Statement was published in the November 2005 Medicine & Science in Sports & ExerciseÒ without two final corrections. The corrected statement is published here in its entirety. Copyright Ó 2006 by the American College of Sports Medicine (ACSM), American Academy of Family Physicians (AAFP), American Academy of Orthopaedic Surgeons (AAOS), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSSM), and the American Osteopathic Academy of Sports Medicine (AOASM).

INTRODUCTION It is essential the team physician understand: • The recognition and evaluation of the athlete with concussion. • Management and treatment of the athlete with concussion be individualized.

0195-9131/06/3802–0395/0 MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ DOI: 10.1249/01.mss.0000202025.48774.31

395 Copyright @ 2006 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

• The factors involved in making return-to-play (RTP) decisions after injury should be based on clinical judgment. • A game-day medical plan specific to concussion injuries be developed. • The need for documentation. • There is a paucity of well-designed studies of concussion and its natural history. It is desirable the team physician: • Coordinate a systematic approach for the treatment of the athlete with concussion. • Identify risk factors and implement appropriate treatment. • Understand the potential sequelae of concussive injuries. • Understand prevention strategies.

EPIDEMIOLOGY • Concussions occur commonly in helmeted and nonhelmeted sports, and account for a significant number of time loss injuries. • Published reports indicate concussion injuries occur at a rate of: • 0.14–3.66 injuries per 100 player seasons at the high school level, accounting for 3–5% of injuries in all sports • 0.5–3.0 injuries per 1,000 athlete exposures at the collegiate level. • Self-report data suggests significantly higher incidence of concussion. • Because of under recognition and/or under reporting, the incidence of concussion and its sequelae is unknown.

PATHOPHYSIOLOGY • Metabolic changes that occur in the animal model, and thought to occur in humans include: • Alterations in intracellular/extracellular glutamate, potassium and calcium • A relative decrease in cerebral blood flow in the setting of an increased requirement for glucose (i.e., increased glycolysis). This mismatch in the metabolic supply and demand may potentially result in cell dysfunction and increase the vulnerability of the cell to a second insult.

GAME-DAY EVALUATION AND TREATMENT It is essential the team physician: • Implement the game-day medical plan specific to concussion. • Understand the indications for cervical spine immobilization and emergency transport. On-Field • Evaluate the injured athlete on-the-field in a systematic fashion: 396

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TABLE 1. Selected acute signs and symptoms suggestive of concussion. Cognitive

Somatic

Affective

Confusion Posttraumatic amnesia (PTA) Retrograde amnesia (RGA) Loss of consciousness (LOC) Disorientation Feeling ‘ in a fog,’’ ‘ zoned out’’ Vacant stare Inability to focus Delayed verbal and motor responses Slurred/incoherent speech Excessive drowsiness

Headache Fatigue Disequilibrium, dizziness Nausea/vomiting Visual disturbances (photophobia, blurry/double vision) Phonophobia

Emotional lability Irritability

• Assess for adequate airway, breathing, and circulation (ABC’s) • Followed by focused neurological assessment emphasizing mental status, neurological deficit, and cervical spine status • Determine initial disposition (emergency transport vs sideline evaluation) Sideline • Obtain a more detailed history and perform a more detailed physical examination. • Assess for cognitive, somatic, and affective signs and symptoms of acute concussion (see Table 1), with particular attention to retrograde amnesia (RGA), posttraumatic amnesia (PTA), and more than brief LOC (minutes, not seconds), because of their prognostic significance. • Not leave the player unsupervised • Perform serial neurological assessments • Determine disposition for symptomatic and nonsymptomatic players, including postinjury follow-up (options include return-to-play, home with observation, or transport to hospital). • Provide postevent instructions to the athlete and others (e.g., regarding alcohol, medications, physical exertion and medical follow-up).

It is desirable the team physician: On-Field • Have a plan to protect access to the injured player • Have emergency medical personnel on-site • Have medical supplies on-site for rescue, immobilization and transportation [See ‘‘Sideline Preparedness for the Team Physician: A Consensus Statement’’; (1)] Sideline • Delineate the mechanism of injury. • Perform a more detailed assessment of cognitive function (e.g., memory, calculations, attention span, concentration, speed of information processing). • Coordinate the care and follow-up of the athlete with concussion. http://www.acsm-msse.org

• Discuss status of athlete with parents, caregivers, certified athletic trainers and coaching staff within disclosure regulations.

POST–GAME-DAY EVALUATION AND TREATMENT It is essential the team physician: • Obtain a comprehensive history of the current concussion, and any previous concussion. • Perform a physical examination, including a detailed neurological/cognitive evaluation. • Determine the need for further evaluation and consultation. • Determine return-to-play status. It is desirable the team physician: • Coordinate the care and follow-up of the athlete. • Understand the indications and limitations of neuropsychological testing. • Postinjury neuropsychological test data are more useful if compared to the athlete’s preinjury baseline. • It is unclear what type and content of test data are most valuable. • It is only one component of the evaluation process. • Educate the athlete and others about concussion. • Discuss status of athlete with parents, caregivers, certified athletic trainers and coaching staff within disclosure regulations.

DIAGNOSTIC IMAGING It is essential the team physician understand: • The limited value of plain skull radiographs. • Indications of advanced imaging, such as CT or magnetic resonance imaging (MRI), to assess associated injuries including intracranial bleed, cerebral edema, diffuse axonal injury, and/or skull fracture. • Indications for the use of cervical imaging when cervical spine injury is suspected.

• Duration of symptoms is a major factor in determining severity, therefore severity of injury should not be determined until all signs and symptoms have cleared. • The treatment of and the RTP decision for the athlete with concussion must be individualized. It is desirable the team physician: • Coordinate a team for concussion management (e.g., physicians, certified athletic trainers, neuropsychologists, emergency response personnel). • Discuss status of athlete with parents, caregivers, certified athletic trainers and coaching staff within disclosure regulations.

RETURN-TO-PLAY (RTP) DECISION The RTP decision should be individualized, and not based on a rigid timeline. The team physician is ultimately responsible for the RTP decision. [See ‘‘The Team Physician and Return-To-Play Issues: A Consensus Statement’’; (2).] It is essential the team physician understand: Same-Day RTP • There is agreement that athletes with significant, persistent or worsening signs and symptoms (e.g., abnormal neurological examination, ongoing RGA or PTA, prolonged LOC) should not RTP. • For other athletes with concussion, significant controversy exists for a same-day RTP decision and no conclusive evidence-based data are available. Areas of controversy include: • Returning an athlete with any symptoms to play. • Returning an athlete with fully resolved symptoms to play. • Certain symptoms, even if resolved, are contraindications to same-day RTP (e.g., any LOC, PTA, and RGA). • The duration and severity of symptoms are the determining factors of RTP. • It is the safest course of action to hold an athlete out.

It is desirable the team physician: • Review the results of the imaging studies and/or ancillary tests such as facial bone radiographs.

MANAGEMENT PRINCIPLES It is essential the team physician understand: • Brief LOC (seconds, not minutes) is associated with specific early deficits, but does not predict the severity of injury; therefore classification systems or RTP guidelines based solely on brief LOC are not accurate. • RGA, PTA, as well as the number and duration of additional signs and symptoms, are more accurate in predicting severity and outcome. RTP guidelines which address these issues are more useful. TEAM PHYSICIAN CONSENSUS STATEMENT

Post–Game-Day RTP • Determine the athlete is asymptomatic at rest before resuming any exertional activity. • Amnesia may be permanent. • Utilize progressive aerobic and resistance exercise challenge tests before full RTP. • Consider factors which may affect RTP, including: • Severity of the current injury • Previous concussions (number, severity, proximity) • Significant injury in response to a minor blow • Age (developing brain may react differently to trauma than mature brain) • Sport • Learning disabilities Medicine & Science in Sports & ExerciseT

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• Understand contraindications for return to sport (e.g., abnormal neurological examination, signs or symptoms with exertion, significant abnormalities on cognitive testing or imaging studies). • Controversy exists for postgame RTP decisions. It is desirable the team physician: Post–Game-Day RTP • Coordinate a team to implement progressive aerobic and resistance exercise challenge tests before full RTP. • Recognize challenging cognitive effort may exacerbate symptoms of concussion and retard recovery. • Discuss status of athlete with parents, caregivers, teachers, certified athletic trainers and coaching staff within disclosure regulations. • Consider neuropsychological testing.

COMPLICATIONS OF CONCUSSION It is essential the team physician: • Understand cumulative concussions may increase risk for subsequent concussions. • Determine when the athlete may RTP. It is also essential the team physician understand other complications may occur, including: • Convulsive motor phenomena • Tonic posturing or convulsive movements within seconds of the concussion • Dramatic, but usually benign • Require no management beyond on-field ABCs • No anticonvulsant therapy required • Posttraumatic seizures • Seizure occurs days to months after concussion • Does require seizure management and precautions • Usually requires anticonvulsant therapy • Postconcussion syndrome • Persistent postconcussion symptoms lasting months • Indicator of concussion severity • Precludes RTP while present • Second impact syndrome • Occurs within minutes of concussion in athlete still symptomatic from prior brain injury

• Prior brain injury can be earlier in same event • Vascular engorgement leads to massive increase in intracranial pressure and brain herniation • Usually with severe brain damage or death • May occur with associated small subdural hemotoma • Except for boxing, all cases in literature in adolescents (G20 yr old) It is desirable the team physician: • Coordinate assessment and treatment of complications • Discuss status of athlete with parents, caregivers, certified athletic trainers and coaching staff within disclosure regulations.

PREVENTION Concussions cannot be completely prevented. It is essential the team physician understand: • Helmet use decreases the incidence of skull fracture and major head trauma, but does not prevent, and may actually increase, the incidence of concussion. • Improper use of the head and improper fit of helmet or protective equipment may increase the risk of concussion. • There are rules to limit concussion (e.g., spearing, head-to-head contact, leading with the head). It is desirable the team physician: • During the preparticipation evaluation, obtain a concussion history. • Discuss the enforcement of rules to limit concussion with coaching staff and officials before practice and competition. • Discuss with players and coaches techniques which may increase the risk of concussion. • Support the use of mouth guards to decrease the risk of dental and facial injury, although the protection they provide to concussion risk is unclear. • Educate athletes, parents, and coaches on the importance of reporting symptoms of concussion to limit complications. • Educate athletes, parents, and coaches regarding the escalation of violence in sports.

REFERENCES 1. AMERICAN COLLEGE OF SPORTS MEDICINE. Sideline preparedness for the team physician: a consensus statement. Med. Sci. Sports Exerc. 33:846–849, 2001.

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2. AMERICAN COLLEGE OF SPORTS MEDICINE. The team physician and return-to-play issues: a consensus statement. Med. Sci. Sports Exerc. 34:1212–1214, 2002.

http://www.acsm-msse.org

SELECTED READINGS BARTH, J. T., W. M. ALVES, T. V. RYAN, ET AL. Mild head injury in sports: neuropsychological sequelae and recovery of function. In: Mild Head Injury, H. S. Levin, H. M. Eisenberg, and A. L. Benton (Eds.). New York: Oxford, 1989, pp. 257–275. CANTU, R. C. Concussion severity should not be determined until all postconcussion symptoms have abated. Lancet 3:437–438, 2004. CANTU, R. C. Recurrent athletic head injury: risks and when to retire. Clin. Sports Med. 22:593–603, 2003. CANTU, R. C. Post traumatic (retrograde/anterograde) amnesia: pathophysiology and implications in grading and safe return to play. J. Ath. Train. 36:244–248, 2001. CENTERS FOR DISEASE CONTROL AND PREVENTION. Sports-related recurrent brain injuries: United States. MMWR 46:224–227, 1997. COLLIE, A., AND P. MARUFF. Computerised neuropsychological testing. Br. J. Sports Med. 37:2–3, 2003. COLLINS, M. W., G. L. IVERSON, M. R. LOVELL, D. B. MCKEAG, J. NORWIG, AND J. C. MAROON. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin. J. Sport Med. 13:222–229, 2003. COLLINS, M. W., M. LOVELL, G. IVERSON, R. C. CANTU, J. C. MAROON, AND M. FIELD. Cumulative effects of concussion in high school athletes. Neurosurgery 51:1175–1179, 2002. COLLINS, M. W., F. FIELD, M. R. LOVELL, ET AL. Relationship between postconcussion headache and neuropsychological test performance in high school athletes. Am. J. Sports Med. 31:168–173, 2003. ECHEMENDIA R. J., M. PUTUKIAN, R. S. MACKIN, L. JULIAN, AND N. SHOSS. Neuropsychological test performance before and following sports-related mild traumatic brain injury. Clin. J. Sport Med. 11:23– 31, 2001. GUSKIEWICZ, K. M., S. L. BRUCE, R. C. CANTU, ET AL. National Athletic Trainers’ Association Position Statement: Management of SportRelated Concussion. J. Ath. Train. 39:280–297, 2004. GUSKIEWICZ, K. M., M. MCCREA, S. W. MARSHALL, ET AL. Cumulative effects of recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 290:2549–2555, 2003.

TEAM PHYSICIAN CONSENSUS STATEMENT

GUSKIEWICZ, K. M., S. E. ROSS, AND S. W. MARSHALL. Postural stability and neuropsychological deficits after concussion in collegiate athletes. J. Athl. Train. 36:263–273, 2001. HOVDA, D. A., S. M. LEE, M. L. SMITH, ET AL. The Neurochemical and metabolic cascade following brain injury: Moving from animal models to man. J. Neurotrauma 12:143–146, 1995. JOHNSTON, K., M. AUBRY, R. C. CANTU, ET AL. Summary and Agreement Statement of the First International Conference on Concussion in Sport, Vienna 2001. Phys. Sportsmed. 30:57–63, 2002. LEZAK, M. Neuropsychological Assessment, 3rd Ed. Oxford Press, 1995. LOVELL, M. R., M. COLLINS, G. IVERSON, ET AL. Recovery from concussion in high school athletes. J. Neurosurgery 98:293–301, 2003. MACCHIOCHI, S. N., J. T. BARTH, W. ALVES, ET AL. Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 39:510–514, 1996. MCCRORY, P., A. COLLIE, V. ANDERSON, AND G. DAVIS. Can we manage sport related concussion in children the same as in adults? Sr. J. Sports Med. 38:516–519, 2004. MCCRORY, P., K. JOHNSTON, W. MEEUWISSE, ET AL. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Sr. J. Sports Med. 39:196–204, 2005. MCKEAG, D. B., M. COLLINS, M. R. LOVELL, AND C. GANGLION. Cumulative effects of concussion in high school and college athletes. Clin. J. Sport Med. 14:310, 2004. PELLMAN, ET AL. Concussion in Professional Football, Neurological Testing—Part 6. Neurosurgery 55:1290–1305, 2004. PELLMAN, ET AL. Concussion in Professional Football, Epidemiological Features of Game Injuries and Review of Literature, Part 3. Neurosurgery 54:81–96, 2004. PUTUKIAN, M. Head injuries in athletics: Mechanisms and management. In: Ortho Knowledge Update, Third edition: Sports Medicine, J. G. Garrick (Ed.). Rosemont, IL: American Academy of Orthopedic Surgeons, 2004, pp. 29–46.

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2010-11 NCAA Sports Medicine Handbook

速

THE NATIONAL COLLEGIATE ATHLETIC ASSOCIATION P.O. Box 6222 Indianapolis, Indiana 46206-6222 317/917-6222 NCAA.org Twenty-first Edition July 2010

Compiled By: David Klossner, Director of Educational Affairs. Distributed to head athletic trainers. Available online at NCAA.org/health-safety. Note: Revisions to the guidelines contained in the NCAA Sports Medicine Handbook may be made on a yearly basis. Between printings of the handbook, revisions will be published on NCAA.org. It is important that persons using this handbook be aware of any such revisions. The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports suggests that such revisions be recorded in the handbook, thereby keeping this publication current. New guidelines and major revisions have been highlighted with orange shading. NCAA, NCAA logo and NATIONAL COLLEGIATE ATHLETIC ASSOCIATION are registered marks of the Association and use in any manner is prohibited unless prior approval is obtained from the Association. Member institutions and conferences may reproduce information in this publication for their own use, provided the NCAA copyright is included on the material. Also found on the NCAA website at the following address: NCAA.org/health-safety. Copyright, 2010, by the National Collegiate Athletic Association. Printed in the United States of America.

PREFACE The health and safety principle of the National Collegiate Athletic Association’s constitution provides that it is the responsibility of each member institution to protect the health of, and provide a safe environment for, each of its participating student-athletes. To provide guidance in accomplishing this objective and to assist member schools in developing a safe intercollegiate athletics program, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports creates a Sports Medicine Handbook. The committee has agreed to formulate guidelines for sports medicine care and protection of studentathletes’ health and safety for topics relevant to intercollegiate athletics, applicable to a large population of student-athletes, and not accessible in another easily obtainable source. This handbook consists of guidelines for each institution to consider in developing sports medicine policies appropriate for its intercollegiate athlet-

ics program. In some instances, accompanying best practices, and references to sports medicine or legal resource materials are provided for further guidance. These recommendations are not intended to establish a legal standard of care that must be strictly adhered to by member institutions. In other words, these guidelines are not mandates that an institution is required to follow to avoid legal liability or disciplinary sanctions by the NCAA. However, an institution has a legal duty to use reasonable care in conducting its intercollegiate athletics program, and guidelines may constitute some evidence of the legal standard of care. These general guidelines are not intended to supersede the exercise of medical judgment in specific situations by a member institution’s sports medicine staff. In all instances, determination of the appropriate care and treatment of student-athletes must be based on the clinical judgment of the institution’s team physician or ath-

letic health care team that is consistent with sound principles of sports medicine care. These recommendations provide guidance for an institution’s athletics administrators and sports medicine staff in protecting student-athletes’ health and safety, but do not establish any rigid requirements that must be followed in all cases. This handbook is produced annually, sent to head athletic trainers, and made available online to directors of athletics, senior woman administrators, faculty athletics representatives, athletic trainers, team physicians, Life Skills coordinators, and student-athlete advisory committees at each member institution, and conference commissioners. Please view the NCAA Sports Medicine Handbook as a tool to help your institution develop its sports medicine administrative policies. Such policies should reflect a commitment to protecting your student-athletes’ health and well-being as well as an awareness of the guidelines set forth in this handbook.

2010-11

Sports Medicine Guidelines Foreword......................................................................................................................................................... 4 1. Administrative Issues a. Sports Medicine Administration......................................................................................................... 6 b. Medical Evaluations, Immunizations and Records............................................................................ 8 c. Emergency Care and Coverage........................................................................................................... 11 d. Lightning Safety.................................................................................................................................. 13 e. Catastrophic Incident in Athletics....................................................................................................... 16 f. Dispensing Prescription Medication................................................................................................... 18 g. Nontherapeutic Drugs......................................................................................................................... 21 h. NCAA Alcohol, Tobacco and Other Drug Education Guidelines.................................................... 22 2. Medical Issues a. Medical Disqualification of the Student-Athlete............................................................................... 26 b. Cold Stress and Cold Exposure.......................................................................................................... 27 c. Prevention of Heat Illness................................................................................................................... 31 d. Weight Loss—Dehydration................................................................................................................. 35 e. Assessment of Body Composition..................................................................................................... 36 f. Nutrition and Athletic Performance.................................................................................................... 41 g. Dietary Supplements........................................................................................................................... 46 h. “Burners” (Brachial Plexus Injuries).................................................................................................. 49 i. Concussion or Mild Traumatic Brain Injury in the Athlete............................................................... 52 j. Skin Infections in Athletics................................................................................................................. 57 k. Menstrual-Cycle Dysfunction............................................................................................................. 64 l. Blood-Borne Pathogens and Intercollegiate Athletics....................................................................... 66 m. The Use of Local Anesthetics in College Athletics........................................................................... 72 n. The Use of Injectable Corticosteroids in Sports Injuries.................................................................. 73 o. Depression: Interventions for Intercollegiate Athletics..................................................................... 75 3. Special Populations a. Participation by the Student-Athlete with Impairment...................................................................... 82 b. Pregnancy in the Student-Athlete....................................................................................................... 84 c. The Student-Athlete with Sickle Cell Trait........................................................................................ 86 4. Equipment a. Protective Equipment.......................................................................................................................... 90 b. Eye Safety in Sports............................................................................................................................ 96 c. Mouthguards........................................................................................................................................ 98 d. Use of the Head as a Weapon in Football and Other Contact Sports............................................... 100 e. Guidelines for Helmet Fitting and Removal in Athletics.................................................................. 101 f. Use of Trampoline and Minitramp..................................................................................................... 104 Appendixes a. NCAA Legislation Involving Health and Safety............................................................................... 108 b. NCAA Injury Surveillance Program Summary................................................................................. 113 c. Acknowledgements............................................................................................................................. 117 d. Banned-Drug Classes.......................................................................................................................... 119 New or significantly revised guidelines are highlighted on this page. Limited revisions are highlighted within the specific guideline.

FOREWORD Shared Responsibility for Intercollegiate Sports Safety

Participation in intercollegiate athletics involves unavoidable exposure to an inherent risk of injury. However, student-athletes rightfully assume that those who sponsor intercollegiate athletics have taken reasonable precautions to minimize the risks of injury from athletics participation. In an effort to do so, the NCAA collects injury data in intercollegiate sports. When appropriate, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports makes recommendations to modify safety guidelines, equipment standards, or a sport’s rules of play. It is important to recognize that rule books, safety guidelines and equipment standards, while helpful means of promoting safe athletics participation, are themselves insufficient to accomplish this goal. To effectively minimize the risks of injury from athletics participation, everyone involved in intercollegiate athletics must understand and respect the intent and objectives of applicable rules, guidelines and standards. The institution, through its athletics

director, is responsible for establishing a safe environment for its student-athletes to participate in its intercollegiate athletics program. Coaches should appropriately warn student-athletes about the sport’s inherent risks of injury and instruct them how to minimize such risks while participating in games, practices and training. The team physician and athletic health care team should assume responsibility for developing an appropriate injury prevention program and providing quality sports medicine care to injured student-athletes. Student-athletes should fully understand and comply with the rules and standard of play that govern their sports and follow established procedures to minimize their risk of injury. In summary, all persons participating in, or associated with, an institution’s intercollegiate athletics program share responsibility for taking steps to reduce effectively the risk of injury during intercollegiate athletic competition.

Adminstrative issues Also found on the NCAA website at: NCAA.org/health-safety

GUIDELINE 1a

Sports Medicine Administration October 1977 â&#x20AC;˘ Revised August 2000

The following components of a safe athletics program are an important part of injury prevention. They should serve both as a checklist and as a guideline for use by athletics administrators in the development of safe programs. 1. Preparticipation Medical Exam. Before student-athletes accept the rigors of any organized sport, their health should be evaluated by qualified medical personnel. Such an examination should determine whether the student-athlete is medically cleared to engage in a particular sport (see NCAAâ&#x20AC;&#x2C6;Bylaw 17.1.5). 2. Health Insurance. Each student-athlete should be covered by individual, parental or institutional medical insurance to defray the costs of significant injury or illness. 3. Preseason Preparation. The student-athlete should be protected from premature exposure to the full rigors of sports. Preseason conditioning should provide the student-athlete with optimal readiness by the first practice. 4. Acceptance of Risk. Any informed consent or waiver by student-athletes (or, if minors, by their parents) should be based on an awareness of the risks of

participating in intercollegiate sports. 5. Planning/Supervision. Safety in intercollegiate athletics can be attained only by appropriate planning for and supervision of practice, competition and travel. 6. Minimizing Potential Legal Liability. Liability must be a concern of responsible athletics administrators and coaches. Those who sponsor and govern athletics programs should accept the responsibility of minimizing the risk of injury. 7. Equitable Medical Care. Member institutions should neither

practice nor condone illegal discrimination on the basis of race, creed, national origin, sex, age, disability, social status, financial status, sexual orientation or religious affiliation within their sports medicine programs. Availability and accessibility to medical resources should be based on established medical criteria (e.g., injury rates, rehabilitation) rather than the sport itself. Member institutions should not place their sports medicine staffs in compromising situations by having them provide inequitable treatment in violation of their medical codes of ethics.

Sports Medicine Administration Institutions should be encouraged to incorporate questions regarding adequacy of medical care, with special emphasis on equitable treatment, in exit interviews with student-athletes. 8. Equipment. Purchasers of equipment should be aware of and use safety standards. In addition, attention should be directed to maintaining proper repair and fitting of equipment at all times in all sports. Student-athletes should: a. Be informed what equipment is mandatory and what constitutes illegal equipment; b. Be provided the mandated equipment; c. Be instructed to wear and how to wear mandatory equipment during participation; and d. Be instructed to notify the coaching staff when equipment becomes unsafe or illegal. 9. Facilities. The adequacy and conditions of the facilities used for particular intercollegiate athletics events should not be overlooked, and periodic examination of the facilities should be conducted. Inspection of the facilities should include not only the competitive area, but also warm-up and adjacent areas. 10. Blood-Borne Pathogens. In 1992, the Occupational Safety and Health Administration (OSHA) developed a standard directed to minimizing or eliminating occupational exposure to bloodborne pathogens. Each member institution should determine the applicability of the OSHA standard to its personnel and facilities. 11. Emergency Care. See Guideline 1c.

GUIDELINE 1b

Medical Evaluations, Immunizations and Records July 1977 • Revised June 2008

Preparticipation medical evaluation. A preparticipation medical evaluation should be required upon a student-athlete’s entrance into the institution’s inter collegiate athletics program (see NCAA Bylaw 17.1.5). This initial evaluation should include a comprehensive health history, immunization history as def ined by current Centers for Disease Control and Prevention (CDC) guidelines and a relevant physical exam, with strong emphasis on the cardiovascular, neurologic and musculoskeletal evaluation. After the initial medical evaluation, an updated history should be performed annually. Further preparticipation physical examinations are not believed to be necessary unless warranted by the updated history or the student-athlete’s medical condition.

The American Heart Association has modified its 1996 recommendation for a cardiovascular screening every two years for collegiate athletes.2 The revision3 recommends cardiovascular screening as a part of the physical exam required upon a student-athlete’s entrance into the intercollegiate athletics program. In subsequent years, an interim

history and blood pressure measurement should be made. Important changes in medical status or abnormalities may require more formal cardiovascular evaluation.

Preparticipation Physical Evaluation (see reference No. 5).

Medical records. Student-athletes have a responsibility to truthfully and fully disclose their medical history and to report any changes in their health to the team’s healthcare provider. Medical records should be maintained during the student-athlete’s collegiate career and should include:

a. Measles, mumps, rubella (MMR);

5. Immunizations. It is recommended that student-athletes be immunized for the following:

b. Hepatitis B; c. Diptheria, tetanus (and boosters when appropriate); and d. Meningitis.

3. Subsequent care and clearances;

6. Written permission, signed annually by the student-athlete, which authorizes the release of medical information to others. Such permission should specify all persons to whom the studentathlete authorizes the information to be released. The consent form also should specify which information may be released and to whom.

4. A comprehensive entry-year health-status questionnaire and an updated health-status questionnaire each year thereafter. Components of the questionnaire should consider recommendations from the American Heart Association (see reference Nos. 2 and 3) and the 4th Edition

Note: Records maintained in the athletic training facility are medical records, and therefore subject to state and federal laws with regard to confidentiality and content. Each institution should obtain from appropriate legal counsel an opinion regarding the confidentiality and

1. A record of injuries, illnesses, new medications or allergies, pregnancies and operations, whether sustained during the competitive season or the off-season; 2. Referrals for and feedback from consultation, treatment or rehabilitation;

Medical Evaluations, Immunizations and Records content of such records in its state. Medical records and the information they contain should be created, maintained and released in accordance with clear written guidelines based on this opinion. All personnel who have access to a student-athlete’s medical records should be familiar with such guidelines and informed of their role in maintaining the student-athlete’s right to privacy. Institutions should consider state statutes for medical records retention (e.g., 7 years, 10 years); institutional policy (e.g., insurance long term retention policy); and professional liability statute of limitations. Follow-up examinations. Those who have sustained a significant injury or illness during the sport season should be given a follow-up examination to re-establish medical clearance before resuming participation in a particular sport. This policy also should apply to pregnant student-athletes after delivery or pregnancy termination. These examinations are especially relevant if the event occurred before the student-athlete left the institution for summer break. Clearance for individuals to return to activity is solely the responsibility of the team physician or that physician’s designated representative.

has competed and used one of the four seasons of competition. • e xtension waiver: An extension waiver deals with time on a student-athlete’s eligibility clock and may be granted if, within a student-athlete’s period of eligibility (five years or 10 semesters), he or she has been denied more than one participation opportunity for reasons beyond the student-athlete’s and the institution’s control. In order to demonstrate that an injury or illness prevented competition and resulted in incapacitation for the remainder of the playing season, an institution needs to provide objective documentation to substantiate the incapacitation. Three key components need to be included in this documentation: 1. Contemporaneous diagnosis of injury/illness; 2. Acknowledgement that the injury/ illness is incapacitating; and 3. Length of incapacitation. For more information about medical hardship waivers, read the complete article at NCAA.org/ health-safety or contact the NCAA’s student-athlete reinstatement staff.

Medical Hardship Waivers. Documentation standards should assist conferences and institutions in designing a medical treatment protocol that satisfies all questions of incapacitation and reflects such in the records. To clarify: • h ardship waiver: A hardship waiver deals with a student-athlete’s seasons of competition and may only be granted if a student-athlete

Medical Evaluations, Immunizations and Records

Medical Documentation Standards Guidelines (from the NCAA) Contemporaneous Diagnosis of Injury ____ Contemporaneous medical documentation that validates timing of injury or illness (Required) ____ Contemporaneous medical documentation that verifies initial severity of injury or illness (demonstrates incapacitation likely results for remainder of season) (Recommended) ____ Operation report(s) or surgery report(s) or emergency room document(s) (Recommended) Acknowledgement that the Injury is Incapacitating ____ Contemporaneous letter or diagnosis from treating physician identifying injury or illness as “incapacitating” OR ____ Non-contemporaneous letter or diagnosis from treating physician identifying injury or illness as “incapacitating” AND ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts) Length of Incapacitaion (verifying opportunity for injured student-athlete to resume playing within championship season in question is medically precluded) ____ Estimated length of incapacitation or recovery time range contained within original contemporaneous medical documentation AND ____ Contemporaneous documentation of follow-up doctors visits (within the estimated time range) in which student-athlete is not cleared to resume playing OR ____ Treatment logs or athletic trainer’s notes (indicating continuing rehabilitation efforts)

References

1. Cook LG, Collins M, Williams WW, et. al.: Prematriculation Immunization Requirements of American Colleges and Universities. Journal of American College Health 42:91-98, 1993. 2. Recommendations and Considerations Related to Pre-Participation Screening for Cardiovascular Abnormalities in Competitive Athletics: 2007 Update: Circulation. Mar 2007; 115:1643-1655. 3. Gardner P, Schaffner W: Immuni zations of Adults. The New England Jour nal of Medicine 328(17):1252-1258, 1993.

4. Hepatitis B Virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee. Morbidity and Mortality Weekly Report 40 (RR-13), 1991. 5. Preparticipation Physical Evaluation. 4th Ed. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society of Sports Medicine, American Orthopaedic Society of Sports Medicine. Published by the American Academy of Pediatrics,

2010. Available at ppesportsevaluation. org. 6. Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. 36th Bethesda Conference. Journal of American College of Cardiology, 45(8), 2005.

GUIDELINE 1c

Emergency Care and Coverage October 1977 â&#x20AC;˘ Revised July 2004

Reasonable attention to all possible preventive measures will not eliminate sports injuries. Each scheduled practice or contest of an institution-sponsored intercollegiate athletics event, and all out-ofseason practices and skills sessions, should include an emergency plan. Like student-athlete well-being in general, a plan is a shared responsibility of the athletics department; administrators, coaches and medical personnel should all play a role in the establishment of the plan, procurement of resources and understanding of appropriate emergency response procedures by all parties. Components of such a plan should include: 1. The presence of a person qualified and delegated to render emergency care to a stricken participant;

whether fixed or mobile, should be assured; 5. All necessary emergency equipment should be at the site or quickly accessible. Equipment should be in good operating condition, and personnel must be trained in advance to use it properly. Additionally, emergency information about the studentathlete should be available both at campus and while traveling for use by medical personnel; 6. An inclement weather policy that includes provisions for decision-making and evacuation plans (See Guideline 1d); 7. A thorough understanding by all parties, including the leadership of visiting teams, of the personnel and procedures associated with the

emergency-care plan; and 8. Certification in cardiopulmonary resuscitation techniques (CPR), first aid, and prevention of disease transmission (as outlined by OSHA guidelines) should be required for all athletics personnel associated with practices, competitions, skills instruction, and strength and conditioning. New staff engaged in these activities should comply with these rules within six months of employment. 9. A member of the institution's sports medicine staff should be empowered to have the unchallengeable authority to cancel or modify a workout for health and safety reasons (i.e., environmental changes), as he or she deems appropriate.

2. The presence or planned access to a physician for prompt medical evaluation of the situation, when warranted; 3. Planned access to early defibrillation; 4. Planned access to a medical facility, including a plan for communication and transportation between the athletics site and the medical facility for prompt medical services, when warranted. Access to a working telephone or other telecommunications device,

Emergency Care and Coverage

Guidelines to Use During a Serious On-Field Player Injury: These guidelines have been recommended for National Football League (NFL) officials and have been shared with NCAA championships staff. 1. Players and coaches should go to and remain in the bench area once medical assistance arrives. Adequate lines of vision between the medical staffs and all available emergency personnel should be established and maintained. 2. Players, parents and nonauthorized personnel should be kept a significant distance away from the seriously injured player or players. 3. Players or non-medical personnel should not touch, move or roll an injured player. 4. Players should not try to assist a teammate who is lying on the field (i.e., removing the helmet or chin strap, or attempting to assist breathing by elevating the waist). 5. Players should not pull an injured teammate or opponent from a pile-up. 6. Once the medical staff begins to work on an injured player, they should be allowed to perform services without interruption or interference. 7. Players and coaches should avoid dictating medical services to the athletic trainers or team physicians or taking up their time to perform such services.

References

1. Halpern BC: Injuries and emergencies on the field. In Mellion MB, Shelton GL, Walsh WM (eds): The Team Physician's Handbook St. Louis, MO: MosbyYearbook, 1990, pp. 128-142. 2. Harris AJ: Disaster plan—A part of the game plan. Athletic Training 23(1):59, 1988. 3. Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics. National Athletic Trainers’ Association, (2952 Stemmons Freeway, Dallas, Texas) 2003.

4. Van Camp SP, et al: Nontraumatic sports death in high school and college athletics. Medicine and Science in Sports and Exercise 27(5):641-647, 1995. 5. Mass Participation Event Management for the Team Physician: A Consensus Statement. Medicine and Science in Sports and Exercise 36(11):2004-2008, 2004. 6. Sideline Preparedness for the Team Physician: A Consensus Statement. Medicine and Science in Sports and Exercise 33(5):846-849, 2001.

7. Laws on Cardiac Arrest and Defibrillators, 2007 update. Available at: www.ncsi.org/programs/health/aed.htm. 8. Inter-Association Task Force Recommendations on Emergency Preparedness and Management of Sudden Cardiac Arrest in High School and College Athletic Programs: A Consensus Statement. Journal of Athletic Training. 42:143-158. 2007. 9. National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine-Injured Athlete. Journal of Athletic Training. 44:306-331. 2009.

GUIDELINE 1d

Lightning Safety July 1997 • Revised June 2007

The NCAA Committee on Com petitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Brian L. Bennett, formerly an athletic trainer with the College of William and Mary Division of Sports Medicine, Ronald L. Holle, a meteorologist, formerly of the National Severe Storms Laboratory (NSSL), and Mary Ann Cooper, M.D., Professor of Emergency Medicine of the University of Illinois at Chicago, in the development of this guideline.

place. The following steps are recommended by the NCAA and NOAA to mitigate the lightning hazard: 1. Designate a person to monitor threatening weather and to make the decision to remove a team or individuals from an athletics site or event. A lightning safety plan should include planned instructions for participants and spectators, designation of warning and all clear signals, proper signage, and designation of safer places for shelter from the lightning.

Lightning is the most consistent and significant weather hazard that may affect intercollegiate athletics. Within the United States, the Nat ional Oceanic and Atmospheric Administration (NOAA) estimates that 60 to 70 fatalities and about 10 times as many injuries occur from lightning strikes every year. While the probability of being struck by lightning is low, the odds are significantly greater when a storm is in the area and proper safety precautions are not followed.

2. Monitor local weather reports each day before any practice or event. Be diligently aware of potential thunderstorms that may form during scheduled intercollegiate athletics events or practices. Weather information can be found through various means via local television news coverage, the Internet, cable and satellite weather programming, or the National Weather Service (NWS) website at www.weather.gov.

Education and prevention are the keys to lightning safety. The references associated with this guideline are an excellent educational resource. Prevention should begin long before any intercollegiate athletics event or practice by being proactive and having a lightning safety plan in

3. Be informed of National Weather Service (NWS) issued thunderstorm “watches” or “warnings,” and the warning signs of developing thunderstorms in the area, such as high winds or darkening skies. A “watch” means conditions are favorable for severe weather to develop in an area; a “warning” means that severe

weather has been reported in an area and for everyone to take the proper precautions. A NOAA weather radio is particularly helpful in providing this information. 4. Know where the closest “safer structure or location” is to the field or playing area, and know how long it takes to get to that location. A safer structure or location is defined as: a. Any building normally occupied or frequently used by people, i.e., a building with plumbing and/or electrical wiring that acts to electrically ground the structure. Avoid using the shower or plumbing facilities and contact with electrical appliances during a thunderstorm. b. In the absence of a sturdy, frequently inhabited building, any vehicle with a hard metal roof (neither a convertible, nor a golf cart) with the windows shut provides a measure of safety. The hard metal frame and roof, not the rubber tires, are what protects occupants by dissipating lightning current around the vehicle and not through the occupants. It is important not to touch the metal framework of the vehicle. Some athletics events rent school buses as safer shelters to place around open courses or fields.

Lightning Safety Dangerous Locations Outside locations increase the risk of being struck by lightning when thunderstorms are in the area. Small covered shelters are not safe from lightning. Dug outs, rain shelters, golf shelters and picnic shelters, even if they are properly grounded for structural safety, are usually not properly grounded from the effects of lightning and side flashes to people. They are usually very unsafe and may actually increase the risk of lightning injury. Other dangerous locations include areas connected to, or near, light poles, towers and fences that can carry a nearby strike to people. Also dangerous is any location that makes the person the highest point in the area. 5. Lightning awareness should be heightened at the first flash of lightning, clap of thunder, and/or other criteria such as increasing winds or darkening skies, no matter how far away. These types of activities should be treated as a warning or “wake-up call” to intercollegiate athletics personnel. Lightning safety experts suggest that if you hear thunder, begin preparation for evacuation; if you see lightning, consider suspending activities and heading for your designated safer locations. The following specific lightning safety guidelines have been developed with the assistance of lightning safety experts. Design your lightning safety plan to consider local safety needs, weather patterns and thunderstorm types. a. As a minimum, lightning safety experts strongly

recommend that by the time the monitor observes 30 seconds between seeing the lightning flash and hearing its associated thunder, all individuals should have left the athletics site and reached a safer structure or location. b. Please note that thunder may be hard to hear if there is an athletics event going on, particularly in stadia with large crowds. Implement your lightning safety plan accordingly. c. The existence of blue sky and the absence of rain are not guarantees that lightning will not strike. At least 10 percent of lightning occurs when there is no rainfall and when blue sky is often visible somewhere in the sky, especially with summer thunderstorms. Lightning can, and does, strike as far as 10 (or more) miles away from the rain shaft. d. Avoid using landline telephones, except in emergency situations. People have been killed while using a landline telephone during a thunderstorm. Cellular or cordless phones are safe alternatives to a landline phone, particularly if the person and the antenna are located within a safer structure or location, and if all other precautions are followed. e. To resume athletics activities, lightning safety experts recommend waiting 30 minutes after both the last sound of thunder and last flash of lightning. If lightning is seen without hearing thunder, lightning may be out of range and therefore less likely to be a

significant threat. At night, be aware that lightning can be visible at a much greater distance than during the day as clouds are being lit from the inside by lightning. This greater distance may mean that the lightning is no longer a significant threat. At night, use both the sound of thunder and seeing the lightning channel itself to decide on re-setting the 30-minute “return-to-play” clock before resuming outdoor athletics activities. f. People who have been struck by lightning do not carry an electrical charge. Therefore, cardiopulmonary resuscitation (CPR) is safe for the responder. If possible, an injured person should be moved to a safer location before starting CPR. Lightning-strike victims who show signs of cardiac or respiratory arrest need prompt emergency help. If you are in a 911 community, call for help. Prompt, aggressive CPR has been highly effective for the survival of victims of lightning strikes. Automatic external defibrillators (AEDs) have become a common, safe and effective means of reviving persons in cardiac arrest. Planned access to early defibrillation should be part of your emergency plan. However, CPR should never be delayed while searching for an AED. Note: Weather watchers, realtime weather forecasts and commercial weather-warning devices are all tools that can be used to aid in decision-making regarding stoppage of play, evacuation and return to play.

Lightning Safety References

1. Cooper MA, Andrews CJ, Holle RL, Lopez RE. Lightning Injuries. In: Auerbach, ed. Management of Wilderness and Environmental Emergencies. 5th ed. C.V. Mosby, 2007:67-108. 2. Bennett BL. A Model Lightning Safety Policy for Athletics. Journal of Athletic Training. 32(3):251-253. 1997. 3. Price TG, Cooper MA: Electrical and Lightning Injuries. In: Marx et al. Rosenâ&#x20AC;&#x2122;s Emergency Medicine, Concepts and Clinical Practice, Mosby, 6th ed.

2006; 22: 67-78. 4. National Lightning Safety Institute website: www.lightningsafety.com. 5. Uman MA. All About Lightning. New York: Dover Publications. 1986. 6. NOAA lightning safety website: www. lightningsafety.noaa.gov. 7. Walsh KM, Hanley MJ, Graner SJ, Beam D, Bazluki J. A Survey of Lightning Safety Policy in Selected Division I Colleges. Journal of Athletic Training. 32(3);206-210. 1997. 8. Walsh KM, Bennett BL, Holle RL,

Cooper MA, Kithil R. National Athletic Trainer's Association Position Statement. Lightning Safety for Athletics and Recreation. Journal of Athletic Training. 35(4);471-477. 2000. 9. Holle RL. 2005: Lightning-caused recreation deaths and injuries. Preprints, 14th Symposium on Education, January 9-13, San Diego, California, American Meteorological Society, 6 pp. 10. The Weather Channel on satellite or cable, and on the Internet at www. weather.com.

GUIDELINE 1e

Catastrophic Incident in Athletics July 2004 • Revised July 2008

The NCAA Committee on Comp etitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Timothy Neal, ATC, Syracuse University, who originally authored this guideline. Catastrophes such as death or permanent disability occurring in intercollegiate athletics are rare. However, the aftermath of a catastrophic incident to a studentathlete, coach or staff member can be a time of uncertainty and confusion for an institution. It is recommended that NCAA member institutions develop their own catastrophic incident guideline to provide information and the support necessary to family members, teammates, coaches and staff after a catastrophe. Centralizing and disseminating the information is best served by developing a catastrophic incident guideline. This guideline should be distributed to administrative, sports medicine and coaching staffs within the athletics department. The guideline should be updated and reviewed annually with the entire staff to ensure information is accurate and that new staff

members are aware of the guideline. Components of a catastrophic incident guideline should include: 1. Definition of a catastrophic incident: The sudden death of a student-athlete, coach or staff member from any cause, or disabling and/or quality of life altering injuries. 2. A management team: A select group of administrators who receive all facts pertaining to the catastrophe. This team works collaboratively to officially communicate information to family members, teammates, coaches, staff, the institution and media. This team may consist of one or more of the following: director of athletics, head athletic trainer, university spokesperson, director of athletic communications and university risk manager. This team may select others to help facilitate fact finding specific to the incident. 3. Immediate action plan: At the moment of the catastrophe, a

checklist of whom to call and immediate steps to secure facts and offer support are items to be included. 4. Chain of command/role delineation: This area outlines each individual’s responsibility during the aftermath of the catastrophe. Athletics administrators, university administrators and support services personnel should be involved in this area. 5. Criminal circumstances: Outline the collaboration of the athletics department with university, local and state law enforcement officials in the event of accidental death, homicide or suicide. 6. Away contest responsibilities: Catastrophes may occur at away contests. Indicate who should stay behind with the individual to coordinate communication and act as a university representative until relieved by the institution. 7. Phone list and flow chart: Phone numbers of all key individuals (office, home, cell)

Catastrophic Incident in Athletics involved in the management of the catastrophe should be listed and kept current. Include university legal counsel numbers and the NCAA catastrophic injury service line number (800/245-2744). A flow chart of who is to be called in the event of a catastrophe is also useful in coordinating communication. 8. Incident Record: A written chronology by the management team of the catastrophic incident is recommended to critique the process and provide a basis for review and enhancement of procedures. 9. Notification Process: After the catastrophic incident, the director of athletics, assistant director of athletics for sports medicine (head athletic trainer), head coach (recruiting coach if available), and university risk manager/legal counsel, as available, will contact the parents/legal guardians/

spouse of the victim. The director of athletics, head coach and others deemed necessary, will inform the team, preferably in person, as soon as possible and offer counseling services and support. 10. Assistance to Visiting Team’s Catastrophic Incident as Host Institution: In the event that a visiting team experiences a catastrophic incident, the host institution may offer assistance by alerting the director of athletics or another member of the catastrophic incident management team in order to make as many resources available as possible to the visiting team. The host institution may assist in contacting the victim’s institution and athletics administration, as well as activating, as appropriate, the host institution’s catastrophic incident guideline to offer support to the visiting team’s student-athletes, coaches and staff.

Catastrophic Injury Insurance Program The NCAA sponsors a catastrophic injury insurance program that covers a student-athlete who is catastrophically injured while participating in a covered intercollegiate athletic activity. The policy has a $90,000 deductible and provides benefits in excess of any other valid and collectible insurance. The policy will pay $25,000 if an insured person dies as a result of a covered accident or sustains injury due to a covered accident which, independent of all other causes, results directly in the death of the insured person within twelve (12) months after the date of such injury. Both catastrophic injuries and sudden deaths should be reported to the NCAA national office insurance staff. For more information, visit NCAA.org. Sample guidelines may be found at NCAA.org/health-safety.

References

1. Neal, TL: Catastrophic Incident Guideline Plan. NATA News: 12, May 2003. 2. Neal, TL: Syracuse University Athletic Department Catastrophic Incident Guideline, 2003.

GUIDELINE 1f

Dispensing Prescription Medication May 1986 â&#x20AC;˘ Revised June 2008

Research sponsored by the NCAA has shown that prescription medications have been provided to Âstudent-athletes by individuals other than persons legally authorized to dispense such medications. This is an important concern because the improper dispensing of both prescription and nonprescription drugs can lead to serious medical and legal consequences. Research also has shown that state and federal regulations regarding packaging, labeling, records keeping and storage of medications have been overlooked or disregarded in the dispensing of medications from the athletic training facility. Moreover, many states have strict regulations regarding packaging, labeling, records keeping and storage of prescription and nonprescription medications. Athletics departments must be concerned about the risk of harm to the student-athletes when these regulations are not followed.

Administering drugs and dispensing drugs are two separate functions. Administration generally refers to the direct application of a single dose of drug. Dispensing is defined as preparing, packaging and labeling a prescription drug or device for subsequent use by a patient. Physicians cannot delegate

to athletic trainers the authority for dispensing prescription medications under current medication-disÂ pensing laws, since athletic trainers are not authorized by law to dispense these drugs under any circumstances. The improper delegation of authority by the physician or the dispensing of prescription medications by the athletic trainer (even with permission of the physician), place both parties at risk for legal liability. If athletics departments choose to provide prescription and/or nonprescription medications, they

must comply with the applicable state and federal laws for doing so. It is strongly encouraged that athletics departments and their team physicians work with their on-site or area pharmacists to develop specific policies. The following items form a minimal framework for an appropriate drugdistribution program in a collegeathletics environment. Since there is extreme variability in state laws, it is imperative for each institution to consult with legal counsel in order to be in full compliance. 1. Drug-dispensing practices are

Dispensing Prescription Medication

Federal Regulations specific to the management of prescription medications in the athletic training medical facility Prescription Drug Marketing Act 21 CFR 5.115 – Sample medication control 21 CFR 1301.23(1) – DEA certificate required for separate locations 21 CFR 1301.75 – Storage of controlled substances 21 CFR 1301.44 – DEA certificate readily retrievable 21 CFR 1301.90 – Security of personnel for handling of controlled substances 21 CFR 1301.92 – Responsibility to report drug diversion 21 CFR 1304.4 – Record-keeping requirements for controlled substances 21 CFR 1304.02(d) – Defines a physician which prescribes, administers, and dispenses controlled substances. 21 CFR 1304.11-12(b) – Inventory requirements for controlled substances 21 CFR 1304.13 – Reconciliation requirements for controlled substances 21 CFR 1305.12 – Reporting a theft of a controlled substance Food, Drug, and Cosmetic Act 21 USC 360(g) – Requirement to utilize a FDA-licensed pharmacy repackager 21 USC 353(b)(2) – Labeling of prescription medications 15 USC 1471 – Packaging of controlled substances and prescription medications 15 USC 1473(b) – Exception to PPPA for prescriber dispensing of non-child safety container Federal Controlled Substance Act 21 USC 824(a)(f) – DEA certificate required 21 USC 802(10) – Prescriber dispensing 21 USC 802(10) – Defines a dispensing physician vs. an individual practitioner 21 USC 823(f) – DEA certificate required for separate locations 21 USC 827(1)(A)(B) – Acquisition and disposition record-keeping requirements for individual practitioners dispensing controlled substances.

subject to and should be in compliance with all state, federal and Drug Enforcement Agency (DEA) regulations. Relevant items include appropriate packaging, label ing, counseling and education, records keeping, and accountability for all drugs dispensed. 2. Certified athletic trainers should not be assigned duties that may be performed only by physicians or

pharmacists. A team physician cannot delegate diagnosis, prescription-drug control or prescription-dispensing duties to athletic trainers. 3. Drug-distribution records should be created and maintained where dispensing occurs in accordance with appropriate legal guidelines. The record should be current and easily accessible by appropriate

medical personnel. 4. All prescription and over-thecounter (OTC) medications should be stored in designated areas that ensure proper environmental (dry with temperatures between 59 and 86 degrees Fahrenheit) and security conditions. 5. All drug stocks should be examined at regular intervals for

Dispensing Prescription Medication removal of any outdated, deteriorated or recalled medications. 6. All emergency and travel kits containing prescription and OTC drugs should be routinely inspected for drug quality and security. 7. Individuals receiving medication should be properly informed about what they are taking and how they

should take it. Drug allergies, chronic medical conditions and concurrent medication use should be documented in the student-athlete’s medical record and readily retrievable. 8. Follow-up should be performed to be sure student-athletes are complying with the drug regimen and to ensure that drug therapy is effective.

References

1. Adherence to Drug-Dispensation and Drug-Administration Laws and Guidelines in Collegiate Athletic Training Rooms. Journal of Athletic Training. 38(3): 252-258, 2003. 2. Anderson WA, Albrecht RR, McKeag DB, et al.: A national survey of alcohol and drug use by college athletes. The Physician and Sportsmedicine 19:91104, 1991. 3. Herbert DL: Dispensing prescription medications to athletes. In Herbert, DL (ed): The Legal Aspects of Sports Medi cine Canton, OH: Professional Sports

Publications, 1991, pp. 215-224. 4. Huff PS: Drug Distribution in the Training Room. In Clinics in Sports Medicine. Philadelphia, WB Saunders Co: 211-228, 1998. 5. Huff PS, Prentice WE: Using Phar macological Agents in a Rehabilitation Program. In Rehabilitation Techniques in Sports Medicine (3rd Ed.) Dubuque, IA, WCB/McGraw-Hill 244-265, 1998. 6. Laster-Bradley M, Berger BA: Eval uation of Drug Distribution Systems in University Athletics Programs: Develop ment of a Model or Optimal Drug

Distribution System for Athletics Programs. Unpublished report, 1991. (128 Miller Hall, Department of Phar macy Care Systems, Auburn University, Auburn, AL 36849-5506) 7. Price KD, Huff PS, Isetts BJ, et.al: University-based sports pharmacy program. American Journal HealthSystems Pharmacy 52:302-309, 1995. 8. National Athletic Trainers’ Association Consensus Statement: Managing Prescriptions and Non-Prescription Medication in the Athletic Training Facility. NATA News. January 2009.

GUIDELINE 1g

Nontherapeutic Drugs July 1981 â&#x20AC;˘ Revised June 2002

The NCAA and professional societies such as the American Medical Association (AMA) and the American College of Sports Medicine (ACSM) denounce the employment of nontherapeutic drugs by student-athletes. These include drugs that are taken in an effort to enhance athletic performance, and those drugs that are used recreationally by student-athletes. Examples include, but are not limited to, alcohol, amphetamines, ephedrine, ma huang, anabolicandrogenic steroids, barbiturates, caffeine, cocaine, heroin, LSD, PCP, marijuana and all forms of tobacco. The use of such drugs is contrary to the rules and ethical principles of athletics competition. The patterns of drug use and the specific drugs change frequently, and it is incumbent upon NCAA member institutions to keep abreast of current trends. The NCAA conducts drug-use surveys of student-athletes in all sports and across all divisions every four years. According to the 2005 NCAA Study of Substance Use Habits of College Student-Athletes, the percentage of student-athletes who use alcohol decreased by 12 percent (88.9-76.9) during the last 16 years, while the percentage of student-athletes who use marijuana during those same 16 years also decreased (27.5-20.3). Among the entire group of studentathletes, the use of amphetamines has continually increased since

1997. Use of spit tobacco is down in all divisions, but more so in Divisions II and III. Cocaine use is up slightly in all divisions since 2001. The full results of the 2005 and past surveys are available to all member institutions and can be used to educate staff and plan educational and treatment programs for its student-athletes. The NCAA maintains a banned drug classes list and conducts drug testing at championship events and yearround random testing in sports. Some NCAA member institutions have developed drug-testing programs to combat the use of nontherapeutic substances. Such programs should follow best practice guidelines established by the NCAA ComÂmittee on Competitive Safeguards and Medical Aspects of

Sports. While not all member institutions have enacted their own drug-testing programs, it is essential to have some type of drug-education program as outlined in Guideline 1h. Drug testing should not be viewed as a replacement for a solid drugeducation program. All medical staff should be familiar with the regulations regarding dispensing medications as listed in Guideline 1f. All member institutions, their athletics staff and their studentathletes should be aware of current trends in drug use and abuse, and the current NCAA list of banned drug classes. It is incumbent upon NCAA member institutions to act as a positive influence in order to combat the use of drugs in sport and society.

References

1. American College of Sports Medicine, Position Stand: The Use of AnabolicAndrogenic Steroids in Sports, 1984. (P.O. Box 1440, Indianapolis, IN 46206-1440) 2. American Medical Association Compendium, Policy Statement: Medical and Non-Medical Use of AnabolicAndrogenic Steroids (105.001), 1990. (P.O. Box 10946, Chicago, IL 60610) 3. American Medical Association

Compendium, Policy Statement: NonTherapeutic Use of Pharmacological Agents by Athletes (105.016), 1990. (P.O. Box 10946, Chicago, IL 60610) 4. NCAA Study of Substance Use Habits of College Student-Athletes. NCAA, P.O. Box 6222, Indianapolis, Indiana 462066222, June 2006. Available at www. NCAA.org.

GUIDELINE 1h

NCAA Alcohol, Tobacco and Other Drug Education Guidelines August 2000 • Revised June 2003, June 2009, June 2010

NCAA Bylaws require that the director of athletics or his or her designee disseminate the list of banned drug classes to all studentathletes and educate them about products that might contain banned drugs. The following provides a framework for member schools to assure they are conducting adequate drug education for all studentathletes. Athletics administrators, coaches and sports medicine personnel should also participate in drug-education sessions. Campus colleagues may provide additional support for your efforts.

In preparation for institution drugeducation programs, annually: ❒ Develop a written policy on alcohol, tobacco and other drugs. This policy should include a statement on recruitment activities, drug testing, disclosure of all medications and supplements, discipline, and counseling or treatment options.

❒ Review the NCAA, conference and institutional drug-testing

program policies and update handbook materials accordingly. ❒ Include the NCAA list of banned drug classes and NCAA written policies in the student-athlete handbook. ❒ Identify NCAA, conference and institutional rules regarding the use of street drugs, performance enhancing substances, and nutritional supplements, and consequences for breaking the rules. ❒ Display posters and other NCAA educational materials in hightraffic areas. ❒ Include the following printed warning in the student-athlete handbook: Before consuming any nutritional/ dietary supplement product, review the product and its label with your athletics department staff. Dietary supplements are not well regulated and may cause a positive drug test result. Any product containing a dietary supplement ingredient is taken at your own risk.*

Tasks and Timelines for educating student-athletes By July 1: ❒ Send out the NCAA list of banned drug classes, the dietary supplement warning and REC* information to all returning student-athletes and known incoming student-athletes. Orientation at Start of Academic Year: ❒ Ensure that student-athletes sign NCAA compliance forms. ❒ Provide student-athletes with a copy of the written drug policies as outlined prior. ❒ Show NCAA Drug-Education and Testing video. ❒ Verbally explain all relevant drug policies with student-athletes and staff: • N CAA banned drug classes (note that all related compounds under each class are banned, regardless if they

NCAA Alcohol, Tobacco and Other Drug Education Guidelines are listed as an example.) • N CAA drug-testing policies and consequences for testing positive, including failure to show or tampering with a urine sample. • R isks of using nutritional/ dietary supplements – read the dietary-supplement warning. • N CAA tobacco use ban during practice or competition. • C onference and institutional drug-testing program policies, if appropriate. • S treet drug use policies and institutional sanctions for violations, if appropriate. Team Meetings:

Throughout the Year:

❒ Repeat the information from the orientation at team meetings throughout the year.

❒ Provide additional drugeducation opportunities using NCAA resources found at www. NCAA.org/drugtesting.

Start of Each New Academic Term: ❒ Repeat the information from the orientation at the start of new academic terms to reinforce messages and to ensure transfer student-athletes are exposed to this information.

*For authoritative information on NCAA banned substances, medications and nutritional supplements, contact the Resource Exchange Center (REC) at 877/202-0769 or www. drugfreesport.com/rec (password ncaa1, ncaa2 or ncaa3).

Medical issues Also found on the NCAA website at: NCAA.org/health-safety

GUIDELINE 2a

Medical Disqualification of the Student-Athlete January 1979 • Revised June 2004

Withholding a student-athlete from activity. The team physician has the final responsibility to determine when a student-athlete is removed or withheld from participation due to an injury, an illness or pregnancy. In addition, clearance for that individual to return to activity is solely the responsibility of the team physician or that physician’s designated representative. Procedure to medically disqualify a student-athlete during an NCAA championship. As the event sponsor, the NCAA seeks to ensure that all student-athletes are

physically fit to participate in its championships and have valid medical clearance to participate in the competition. 1. The NCAA tournament physician, as designated by the host school, has the unchallengeable authority to determine whether a student-athlete with an injury, illness or other medical condition (e.g., skin infection) may expose others to a significantly enhanced risk of harm and, if so, to disqualify the student-athlete from continued participation. 2. For all other incidents, the

student-athlete’s on-site team physician can determine whether a student-athlete with an injury or illness should continue to participate or is disqualified. In the absence of a team physician, the NCAA tournament physician will examine the student-athlete and has valid medical authority to disqualify him or her if the student-athlete’s injury, illness or medical condition poses a potentially life threatening risk to himself or herself. 3. The chair of the governing sports committee (or a designated representative) shall be responsible for administrative enforcement of the medical judgment, if it involves disqualification.

References

1. Team Physician Consensus Statement. Project-based alliance for the advancement of clinical sports medicine composed of the American Academy of Family Physicians, the American Academy of Orthopedic Surgeons, the American College of Sports Medicine (ACSM), the American Medical Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine, 2000. Contact ACSM at 317/ 637-9200.

GUIDELINE 2b

Cold Stress and Cold Exposure June 1994 â&#x20AC;˘ Revised June 2002, June 2009

Any individual can lose body heat when exposed to cold air, but when the physically active cannot maintain heat, cold exposure can be uncomfortable, impair performance and may be lifethreatening. A person may exhibit cold stress due to environmental or non-environmental factors. The NATA position statement (2008) states that injuries from cold

exposure are due to a combination of low air or water temperatures and the influence of wind on the bodyâ&#x20AC;&#x2122;s ability to maintain a normothermic core temperature, due to localized exposure of extremities to cold air or surface. The variance in the degree, signs and symptoms of cold stress may also be the result of nonenvironmental factors. These

factors are, but not limited to, previous cold weather injury (CWI), race, geological origin, ambient temperature, use of medications, clothing attire, fatigue, hydration, age, activity, body size/composition, aerobic fitness level, clothing, acclimatization and low caloric intake. Nicotine, alcohol and other drugs may also contribute to how

Wind Chill Chart

See reprint access permission for .gov websites: http://www.weather.gov/om/reprint.shtml

Cold Stress and Cold Exposure the person adapts to the stresses of cold. Early recognition of cold stress is important. Shivering, a means for the body to generate heat, serves as an early warning sign. Excessive shivering contributes to fatigue and makes performance of motor skills more difficult. Other signs include numbness and pain in fingers and toes or a burning sensation of the ears, nose or exposed flesh. As cold exposure continues, the core temperature drops. When the cold reaches the brain, a victim may exhibit sluggishness, poor judgment and may appear disoriented. Speech becomes slow and slurred, and movements become clumsy. If the participant wants to lie down and rest, the situation is a medical emergency and the emergency action plan should be activated. Cold injuries can be classified into three categories: freezing or nonfreezing of extremities and hypothermia.

Definitions of Common Cold Injuries in Sports Frostbite Frostbite is usually a localized response to a cold, dry environment, but in some incidents, moisture may exacerbate the condition. Frostbite can appear in three distinct phases: frostnip, mild frostbite and deep frostbite. Frostnip, also known as prefreeze, is a precursor to frostbite and many times occurs when skin is in contact with cold surfaces (e.g., sporting implements or liquid). The most characteristic symptom is a loss of sensation.

Frostbite is the actual freezing of skin or body tissues, usually of the face, ears, fingers and toes, and can occur within minutes. Signs and

symptoms include edema, redness or mottled gray skin, and transient tingling and burning. Hypothermia Hypothermia is a significant drop in body temperature [below 95 degrees Fahrenheit (35 degrees Celsius)] as the bodyâ&#x20AC;&#x2122;s heat loss exceeds its production. The body is unable to maintain a normal core temperature. An individual may exhibit changes in motor function (e.g., clumsiness, loss of finger dexterity, slurred speech), cognition (e.g., confusion, memory loss) and loss of consciousness (e.g., drop in heart rate, stress on the renal system, hyperventilation, sensation of shivering). The signs and symptoms of hypothermia will vary with each individual, depending upon previous cold weather injury (CWI), race, geological origin, ambient temperature, use of medications, clothing attire, fatigue, hydration, age, activity, and others. Hypothermia can occur at temperatures above freezing. A wet and windy 30- to 50-degree exposure may be as serious as a subzero exposure. As the WindChill Equivalent Index (WCEI) indicates, wind speed interacts with ambient temperature to significantly increase body cooling. When the body and clothing are wet, whether from sweat, rain, snow or immersion, the cooling is even more pronounced due to evaporation of the water held close to the skin by wet clothing. Chilblain and Immersion (Trench) Foot Chilblain is a non-freezing cold injury associated with extended cold and wet exposure and results in an exaggerated or inflammatory response. Chilblain may be observed in exposure to cold, wet conditions extending beyond one

hour in endurance and alpine events, and team sports, in which clothing remains wet. The feet and hands are usually affected.

Prevention of Cold Exposure and Cold Stress Educating all participants in proper prevention is the key to decreasing the possibility of cold exposure injury or illness. Individuals unaccustomed to cold conditions participating at venues that may place them at risk for cold stress may need to take extra precautionary measures (e.g., proper clothing, warm-up routines, nutrition, hydration, sleep). The sports medicine staff and coaches should identify participants or conditions that may place members of their teams at a greater risk (e.g., predisposing medical conditions, physiological factors, mechanical factors, environmental conditions). Clothing Individuals should be advised to dress in layers and try to stay dry. Moisture, whether from perspiration or precipitation, significantly increases body heat loss. Layers can be added or removed depending on temperature, activity and wind chill. Begin with a wicking fabric next to the skin; wicking will not only keep the body warm and dry, but also eliminates the moisture retention of cotton. Polypropylene or wool wick moisture away from the skin and retain insulating properties when wet. Add lightweight pile or wool layers for warmth and use a wind-blocking garment to avoid wind chill. Because heat loss from the head and neck may account for as much as 40 percent of total heat loss, the head and ears should be covered

Cold Stress and Cold Exposure during cold conditions. Hand coverings should be worn as needed and in extreme conditions, a scarf or facemask should be worn. Mittens are warmer than gloves. Feet can be kept dry by wearing moisture-wicking or wool socks that breathe and should be dried between wears. Energy/Hydration Maintain energy levels via the use of meals, energy snacks and carbohydrate/electrolyte sports drinks. Negative energy balance increases the susceptibility to hypothermia. Stay hydrated, since dehydration affects the body’s ability to regulate temperature and increases the risk of frostbite. Fluids are as important in the cold as in the heat. Avoid alcohol, caffeine, nicotine and other drugs that cause water loss, vasodilatation or vasoconstriction of skin vessels. Fatigue/Exhaustion Fatigue and exhaustion deplete energy reserves. Exertional fatigue and exhaustion increase the susceptibility to hypothermia, as does sleep loss. Warm-Up Warm-up thoroughly and keep warm throughout the practice or competition to prevent a drop in muscle or body temperature. Time the warm-up to lead almost immediately to competition. After competition, add clothing to avoid rapid cooling. Warm extremely cold air with a mask or scarf to prevent bronchospasm. Partner Participants should never train alone. An injury or delay in recognizing early cold exposure symptoms could become lifethreatening if it occurs during a cold-weather workout on an isolated trail.

Practice and Competition Sessions The following guidelines, as outlined in the 2008 NATA position statement, can be used in planning activity depending on the windchill temperature. Conditions should be constantly re-evaluated for change in risk, including the presence of precipitation: • 3 0 degrees Fahrenheit and below: Be aware of the potential for cold injury and notify appropriate personnel of the potential. • 2 5 degrees Fahrenheit and below: Provide additional protective clothing; cover as much exposed skin as practical; provide opportunities and facilities for re-warming. • 1 5 degrees Fahrenheit and below: Consider modifying activity to limit exposure or to allow more frequent chances to re-warm. • 0 degrees Fahrenheit and below: Consider terminating or rescheduling activity.

Environmental Conditions To identify cold stress conditions, regular measurements of environmental conditions are recommended during cold conditions by referring to the Wind-Chill Equivalent Index (WCEI) (revised November 1, 2001). The WCEI is a useful tool to monitor the air temperature index that measures the heat loss from exposed human skin surfaces. Wind chill is the temperature it “feels like” outside, based on the rate of heat loss from exposed skin caused by the effects of the wind and cold. Wind removes heat from the body in addition to the low ambient temperature.

When traveling to areas of adverse weather conditions, the following terms will be consistently referred to in weather forecasting. Wind Chill Increased wind speeds accelerate heat loss from exposed skin, and the wind chill is a measure of this effect. No specific rules exist for determining when wind chill becomes dangerous. As a general guideline, the threshold for potentially dangerous wind chill conditions is about minus-20 degrees Fahrenheit. Wind Chill Advisory The National Weather Service issues this product when the wind chill could be life threatening if action is not taken. The criteria for this warning vary from state to state. Wind Chill Factor Increased wind speeds accelerate heat loss from exposed skin. No specific rules exist for determining when wind chill becomes dangerous. As a general rule, the threshold for potentially dangerous wind chill conditions is about minus-20 degrees Fahrenheit. Wind Chill Warning The National Weather Service issues this product when the wind chill is life threatening. The criteria for this warning vary from state to state. Blizzard Warning The National Weather Service issues this product for winter storms with sustained or frequent winds of 35 miles per hour or higher with considerable falling and/or blowing snow that frequently reduces visibility to onequarter of a mile or less.

Cold Stress and Cold Exposure

References

1. Cappaert, Thomas A etal: National Athletic Trainers’ Association Position Statement: Environmental Cold Injuries. Journal of Athletic Training 2008:43(6):640-658 2. Prevention of Cold Injuries During Exercise. ACSM Position Stand. Medicine & Science in Sports & Exercise. 2006: 2012-2029. 3. Armstrong, LE: Performing in Extreme Environments. Champaign, IL: Human Kinetics Publishers.

4. Askew EW: Nutrition for a cold environment. The Physician and Sportsmedicine 17(12):77-89, 1989. 5. Frey C: Frostbitten feet: Steps to treatment and prevention. The Physician and Sportsmedicine 21(1):67-76, 1992. 6. Young, A.J., Castellani, J.W., O’Brian, C. et al., Exertional fatigue, sleep loss, and negative-energy balance increases susceptibility to hypothermia. Journal of Applied Physiology. 85:1210-1217, 1998. 7. Robinson WA: Competing with the

cold. The Physician and Sportsmedicine 20(1):61-65, 1992. 8. Thornton JS: Hypothermia shouldn’t freeze out cold-weather athletes. The Physician and Sportsmedicine 18(1): 109-114, 1990. 9. NOAA National Weather Service, www. weather.gov/om/windchill/images/windchill-brochure.pdf. 10. Street, Scott, Runkle, Debra. Athletic Protective Equipment: Care, Selection, and Fitting. McGraw-Hill, 2001.

GUIDELINE 2c

Prevention of Heat Illness June 1975 • Revised June 2002, June 2010

Practice or competition in hot and/or humid environmental conditions poses special problems for studentathletes. Heat stress and resulting heat illness is a primary concern in these conditions. Although deaths from heat illness are rare, exertional heat stroke (EHS) is the third-leading cause of on-the-field sudden death in athletes. There have been more deaths from heat stroke in the last five-year block (2005-2009) than any other five-year block during the past 35 years. Constant surveillance and education are necessary to prevent heat-related problems. The following practices should be observed: 1. An initial complete medical history and physical evaluation, followed by the completion of a yearly healthstatus questionnaire before practice begins, is required, per Bylaw 17.1.5. A history of previous heat illnesses, sickle cell trait and the type and duration of training activities for the previous month, should also be considered. 2. Prevention of heat illness begins with gradual acclimatization to environmental conditions. Studentathletes should gradually increase exposure to hot and/or humid environmental conditions during a minimum period of 10 to 14 days. Each exposure should involve a gradual increase in the intensity and duration of exercise and equipment worn until the exercise is comparable to

that likely to occur in competition. When environmental conditions are extreme, training or competition should be held during a cooler time of day. Hydration should be maintained during training and acclimatization sessions.

loosened to allow heat dissipation. During the acclimatization process, it may be advisable to use a minimum of protective gear and clothing and to practice in T-shirts, shorts, socks and shoes. Rubberized suits should not be worn.

3. Clothing and protective equipment, such as helmets, shoulder pads and shin guards, increase heat stress by interfering with the evaporation of sweat and inhibiting other pathways needed for heat loss. Darkcolored clothing increases the body’s absorption of solar radiation, while moisture wicking-type clothing helps with the body’s ability to dissipate heat. Frequent rest periods should be scheduled so that the gear and clothing can be removed and/or

4. To identify heat stress conditions, regular measurements of environmental conditions are recommended. The wet-bulb globe temperature (WBGT), which includes the measurement of wet-bulb temperature (humidity), dry-bulb temperature (ambient temperature) and globe temperature (radiant heat), assesses the potential impact of environmental heat stress. A WBGT higher than 82 degrees Fahrenheit (28 degrees Celsius) suggests that careful control

Prevention of Heat Illness of all activity should be undertaken. Additional precautions should be taken when wearing protective equipment (see reference No. 6). The American College of Sports Medicine has recently (2007) revised its guidelines for conducting athletic activities in the heat (see reference No. 1). 5. EHS has the greatest potential of occurrence at the start of preseason practices and with the introduction of protective equipment during practice sessions. The inclusion of multiple practice sessions during the same day may also increase the risk of EHS. Ninety-six percent of all heat illnesses in football occur in August. 6. Hydration status also may influence the occurrence of EHS, therefore fluid replacement should be readily available. Student-athletes should be encouraged to drink frequently throughout a practice session. They should drink two cups or more of water and/or sports drink in the hour before practice or competition, and continue drinking during activity (every 15 to 20 minutes). For activities up to two hours in duration, most weight loss represents water loss, and that fluid loss should be replaced as soon as possible. After activity, the student-athlete should rehydrate with a volume that exceeds the amount lost during the activity. In general, 16-24 ounces of fluid should be replaced for every pound lost. Urine volume and color can be used to assess general hydration. If output is plentiful and the color is “pale yellow or straw-colored,” the student-athlete is not dehydrated. As the urine color gets darker, this could represent dehydration of the student-athlete. Water and sport drinks are appropriate for

hydration and rehydration during exercise in the heat. Sport drinks should contain carbohydrates and electrolytes to enhance fluid consumption. In addition, the carbohydrates provide energy and help maintain immune and cognitive function. 7. During the preseason period or periods of high environmental stress, the student-athletes’ weight should be recorded before and after every workout, practice and competition. This procedure can detect progressive dehydration and loss of body fluids. Those who lose five percent of their body weight or more should be evaluated medically and their activity restricted until rehydration has occurred. For prevention, the routine measurement of pre- and post-exercise body weights is useful for determining sweat rates and customizing fluid replacement programs. 8. Some student-athletes may be more susceptible to heat illness. Susceptible individuals include those with: sickle cell trait, inadequate acclimatization or aerobic fitness, excess body fat, a history of heat illness, a febrile condition, inadequate rehydration, and those who regularly push themselves to capacity. Also, substances with a diuretic effect or that act as stimulants may increase risk of heat illness. These substances may be found in some prescription and over-the-counter drugs, nutritional supplements and foods. 9. Student-athletes should be educated on the signs and symptoms of EHS, such as: elevated core temperature, weakness, cramping, rapid and weak pulse, pale or flushed skin, excessive fatigue, nausea, unsteadiness, disturbance of vision, mental confusion and incoherency. If heat

stroke is suspected, prompt emergency treatment is recommended. When training in hot and/or humid conditions, student-athletes should train with a partner or be under observation by a coach or athletic trainer.

First aid for heat illness Heat exhaustion—Heat exhaustion is a moderate illness characterized by the inability to sustain adequate cardiac output, resulting from strenuous physical exercise and environmental heat stress. Symptoms usually include profound weakness and exhaustion, and often dizziness, syncope, muscle cramps, nausea and a core temperature below 104 degrees Fahrenheit with excessive sweating and flushed appearance. First aid should include removal from activity, taking off all equipment and placing the student-athlete in a cool, shaded environment. Fluids should be given orally. Core temperature and vital signs should be serially assessed. The student-athlete should be cooled by ice immersion and ice towels, and use of IV fluid replacement should be determined by a physician. Although rapid recovery is typical, student-athletes should not be allowed to practice or compete for the remainder of that day. Exertional Heatstroke—Heatstroke is a medical emergency. Medical care should be obtained at once; a delay in treatment can be fatal. This condition is characterized by a very high body temperature (104 degrees Fahrenheit or greater) and the student-athlete likely will still be sweating profusely at the time of collapse, but may have hot, dry skin, which indicates failure of the primary temperature-regulating mechanism

Prevention of Heat Illness (sweating), and CNS dysfunction (e.g., altered consciousness, seizure, coma). First aid includes activation of the emergency action plan, assessment of core temperature/vital signs and immediate cooling of the body with cold water immersion. Another method for cooling includes using cold, wet ice towels on a rotating basis. Student-athletes who incur heatstroke should be hospitalized and monitored carefully. The NATA’s Inter-Association Task Force recommends, “cool first, transport second” in these situations (see reference No. 7). Athletes presenting with any of these signs and symptoms should be referred to a healthcare professional and basic steps taken while awaiting such medical care. Many other potentially life-threatening conditions can present as a heat illness and emphasis should be placed on proper medical diagnosis.

POTENTIAL RISK FACTORS As identified throughout Guideline 2c, the following are potential risk factors associated with heat illness: 1. Intensity of exercise. This is the leading factor that can increase core body temperature higher and faster than any other. 2. Environmental conditions. Heat and humidity combine for a high wet-bulb globe temperature that can quickly raise the heat stress on the body. 3. Duration and frequency of exercise. Minimize multiple practice sessions during the same day and allow at least three hours of recovery between sessions. 4. Dehydration. Fluids should be readily available and consumed to aid in the body’s ability to regulate itself and reduce the impact of heat stress. 5. Nutritional supplements. Nutritional supplements may contain stimulants, such as ephedrine, ma huang or high levels of caffeine.* These substances can have a negative impact on hydration levels and/or increase metabolism and heat production. They are of particular concern in people with underlying medical conditions such as sickle cell trait, hypertension, asthma and thyroid dysfunction. 6. Medication/drugs. Certain medications and drugs have similar effects as nutritional supplements. These substances may be ingested through over-thecounter or prescription medications, recreational drugs, or consumed in food. Examples include antihistamines, decongestants, certain asthma medications, Ritalin, diuretics and alcohol. 7. Medical conditions. Examples include illness with fever, gastro-intestinal illness, previous heat illness, obesity or sickle cell trait. 8. Acclimatization/fitness level. Lack of acclimatization to the heat or poor conditioning. 9. Clothing. Dark clothing absorbs heat. Moisture wicking-type material helps dissipate heat. 10. Protective equipment. Helmets, shoulder pads, chest protectors, and thigh and leg pads interfere with sweat evaporation and increase heat retention. 11. Limited knowledge of heat illness. Signs and symptoms can include elevated core temperature, pale or flushed skin, profound weakness, muscle cramping, rapid weak pulse, nausea, dizziness, excessive fatigue, fainting, confusion, visual disturbances and others. *NOTE: Stimulant drugs such as amphetamines, ecstasy, ephedrine and caffeine are on the NCAA banned substance list and may be known by other names. A complete list of banned drug classes can be found on the NCAA website at NCAA.org/health-safety.

Prevention of Heat Illness References

1. American College of Sports Medicine Position Stand: Exertional Heat Illness during Training and Competition. Med: Sci Sport Exerc. 2007;39(3):556-72. 2. Armstrong LE, Maresh CM: The induction and decay of heat acclimatization in trained athletes. Sports Medicine 12(5):302-312, 1991. 3. Armstrong, LE: Performing in Extreme Environments. Champaign, IL: Human Kinetics Publishers, pp 64, 2000. 4. Haynes EM, Wells CL: Heat stress and performance. In: Environment and Human Performance. Champaign, IL: Human Kinetics Publishers, pp. 13-41, 1986. 5. Hubbard RW and Armstrong LE: The heat illness: Biochemical, ultrastructural and fluid-electrolyte considerations. In Pandolf KB, Sawka MN and Gonzalez RR (eds): Human Performance Physiology and Environmental Medicine at Terrestial Extremes. Indianapolis, IN: Benchmark Press, Inc., 1988. 6. Kulka TJ and Kenney WL: Heat balance limits in football uniforms. The Physician and Sportsmedicine. 30(7): 29-39, 2002. 7. Inter-Association Task Force on Exertional Heat Illnesses Consensus Statement. National Athletic Trainers’ Association, June 2003.

8. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional Heat Stroke in Competitive Athletes. Current Sports Medicine Reports 2005, 4:309–317. 9. Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh CM. Cold Water Immersion: The Gold Standard for Exertional Heatstroke Treatment. Exercise and Sport Sciences Reviews. 2007. 35:141-149. 10. Casa DJ, Becker SM, Ganio MS, et al. Validity of Devices That Assess Body Temperature During Outdoor Exercise in the Heat. Journal of Athletic Training 2007; 42(3):333–342. 11. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training 2002; 37(3):329–343. 12. American College of Sports Medicine Position Stand: Exercise and Fluid Replacement. Med: Sci Sport Exerc. 2007; 384-86.

GUIDELINE 2d

Weight Loss– Dehydration July 1985 • Revised June 2002

There are two general types of weight loss common to studentathletes who participate in intercollegiate sports: loss of body water or loss of body weight (fat and lean tissue). Dehydration, the loss of body water, leads to a state of negative water balance called dehydration. It is brought about by withholding fluids and carbohydrates, the promotion of extensive sweating and the use of emetics, diuretics or laxatives. The problem is most evident in those who must be certified to participate in a given weight class, but it also is present in other athletics groups. There is no valid reason for subjecting the student-athlete’s body to intentional dehydration, which can lead to a variety of adverse physiological effects, including significant pathology and even death. Dehydration in excess of 3 to 5 percent leads to reduced strength and

muscular endurance, reduced plasma and blood volume, compromised cardiac output (elevated heart rate, smaller stroke volume), impaired thermoregulation, decreased kidney blood flow and filtration, reduced liver glycogen stores, and loss of electrolytes. Pathological responses include life-threatening heat illness, rhabdomyolysis (severe muscle breakdown), kidney failure and cardiac arrest. With extensive dehydration, attempts at acute rehydration usually are insufficient for body fluid and electrolyte homeostasis to be restored before competition. For example, in wrestling this is especially true between the official weigh-in and actual competition. All respected sports medicine authorities and organizations have condemned the practice of fluid deprivation. To promote sound

References

1. American College of Sports Medicine, Position Stand: Weight Loss in Wrestlers, 1995. (P.O. Box 1440, Indianapolis, IN 46206-1440). 2. Armstrong, LE. Performing in Extreme Environments. Champaign, IL: Human Kinetics Publishers, pp 15-70, 2000. 3. Horswill CA: Does Rapid Weight Loss by Dehydration Adversely Affect HighPower Performance? 3(30), 1991. (Gatorade Sports Science Institute, P.O.

Box 9005, Chicago, IL 60604-9005). 4. Hyphothermia and DehydrationRelated Deaths Associated with Intentional Rapid Weight Loss in Three Collegiate Wrestlers. Morbidity and Mortality Weekly 47(6):105-108, 1998. 5. Sawka, MN (chair): Symposium— Current concepts concerning thirst, dehydration, and fluid replacement. Medicine and Science in Sports and Exercise 24(6):643-687, 1992.

practices, student-athletes and coaches should be educated about the physiological and pathological consequences of dehydration. The use of laxatives, emetics and diuretics should be prohibited. Similarly, the use of excessive food and fluid restriction, self-induced vomiting, vapor-impermeable suits (e.g., rubber or rubberized nylon), hot rooms, hot boxes and steam rooms should be prohibited. Excessive food restriction or selfinduced vomiting may be symptoms of serious eating disorders (see Guideline 2f). Dehydration is a potential health hazard that acts with poor nutrition and intense exercise to compromise health and athletic performance. The sensible alternative to dehydration weight loss involves: preseason determination of an acceptable (minimum) competitive weight, gradual weight loss to achieve the desired weight, and maintenance of the weight during the course of the competitive season. Standard body composition procedures should be used to determine the appropriate competitive weight. Spot checks (body composition or dehydration) should be used to ensure compliance with the weight standard during the season. Student-athletes and coaches should be informed of the health consequences of dehydration, educated in proper weight-loss procedures, and subject to disciplinary action when approved rules are violated.

GUIDELINE 2e

Assessment of Body Composition June 1991 • Revised June 2002

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. Dan Benardot, Georgia State University, who authored a revision of this guideline. Athletic performance is, to a great degree, dependent on the ability of the student-athlete to overcome resistance and to sustain aerobic and/or anaerobic power. Both of these elements of performance have important training and nutritional components and are, to a large degree, influenced by the student-athlete’s body composition. Coupled with the common perception of many student-athletes who compete in sports in which appearance is a concern (swimming, diving, gymnastics, skating, etc.), attainment of an ‘ideal’ body composition often becomes a central theme of training.

Successful student-athletes achieve a body composition that is within a range associated with performance achievement in their specific sport. Each sport has different norms for the muscle and fat levels associated with a given height, and the student-athlete’s natural genetic predisposition for a certain body composition may encourage them to participate in a particular sport or take a specific position within a sport. For instance, linemen on

football teams have different responsibilities than receivers, and this difference is manifested in physiques that are also different. Besides the aesthetic and performance reasons for wanting to achieve an optimal body composition, there may also be safety reasons. A student-athlete who is carrying excess weight may be more prone to injury when performing difficult skills than the student-athlete with a more optimal body composition. However, the means student-athletes often use in an attempt to achieve an optimal body composition may be counterproductive. Diets and excessive training often result in such a severe energy deficit that, while total weight may be reduced, the constituents of weight also change, commonly with a lower muscle mass and a relatively higher fat mass. The resulting higher

body fat percentage and lower muscle mass inevitably results in a performance reduction that motivates the student-athlete to follow regimens that produce even greater energy deficits. This downward energy intake spiral may be the precursor to eating disorders that place the student-athlete at serious health risk. Therefore, while achieving an optimal body composition is useful for high-level athletic performance, the processes student-athletes often use to attain an optimal body composition may reduce athletic performance, may place them at a higher injury risk and may increase health risks.

Purpose of Body Composition Assessment The purpose of body composition assessment is to determine the student-athlete’s distribution of lean (muscle) mass and fat mass. A

Assessment of Body Composition high lean mass to fat mass ratio is often synonymous with a high strength to weight ratio, which is typically associated with athletic success. However, there is no single ideal body composition for all student-athletes in all sports. Each sport has a range of lean mass and fat mass associated with it, and each student-athlete in a sport has an individual range that is ideal for him or her. Studentathletes who try to achieve an arbitrary body composition that is not right for them are likely to place themselves at health risk and will not achieve the performance benefits they seek. Therefore, a key to body composition assessment is the establishment of an acceptable range of lean and fat mass for the individual studentathlete, and the monitoring of lean and fat mass over regular time intervals to assure a stability or growth of the lean mass and a proportional maintenance or reduction of the fat mass. Importantly, there should be just as much attention given to changes in lean mass (both in weight of lean mass and proportion of lean mass) as the attention traditionally given to body fat percent. In the absence of published standards for a sport, one strategy for determining if a student-athlete is within the body composition standards for the sport is to obtain a body fat percent value for each student-athlete on a team (using the same method of assessment), and obtaining an average and standard deviation for body fat percent for the team. Student-athletes who are within 1 standard deviation (i.e., a Z-score of ± 1) of the team mean should be considered within the range for the sport. Those greater than or less than ± 1 standard deviation should be evaluated to

determine the appropriateness of their training schedule and nutrient intake. In addition, it is important for coaches and student-athletes to use functional performance measures in determining the appropriateness of a studentathlete’s body composition. Student-athletes outside the normal range of body fat percent for the sport may have achieved an optimal body composition for their genetic makeup, and may have objective performance measures (e.g., jump height) that are well within the range of others on the team. Body composition can be measured indirectly by several methods, including hydrostatic weighing, skinfold and girth measurements (applied to a nomogram or prediction equation), bioelectrical impedance analysis (BIA), dualenergy x-ray absorptiometry (DEXA), ultrasound, computerized tomography, magnetic-resonance imagery, isotope dilution, neutronactivation analysis, potassium-40 counting, and infrared interactance. The most common of the methods now used to assess body composition in student-athletes are skinfold measurements, DEXA, hydrostatic weighing and BIA. While hydrostatic weighing and DEXA are considered by many to be the “gold standards” of the indirect measurement techniques, there are still questions regarding the validity of these techniques when applied to humans. Since skinfold-based prediction equations typically use hydrostatic weighing or DEXA as the criterion methods, results from skinfolds typically carry the prediction errors of the criterion methods plus the added measurement errors associated with obtaining skinfold values. BIA has become popular because of its non-

In the absence of published standards for a sport, one strategy for determining if a student-athlete is within the body composition standards for the sport is to obtain a body fat percent value for each student-athlete on a team (using the same method of assessment), and obtaining an average and standard deviation for body fat percent for the team.

Assessment of Body Composition invasiveness and speed of measurement, but results from this technique are influenced by hydration state. Since studentathletes have hydration states that are in constant flux, BIA results may be misleading unless strict hydration protocols are followed. In general, all of the commonly used techniques should be viewed as providing only estimates of body composition, and since these techniques use different theoretical assumptions in their prediction of body composition, values obtained from one technique should not be compared with values obtained from another technique.

Concerns with Body Composition Assessment 1. Using Weight as a Marker of Body Composition—While the collection of weight data is a necessary adjunct to body composition assessment, by itself weight may be a misleading value. For instance, young studentathletes have the expectation of growth and increasing weight, so gradual increases in weight should not be interpreted as a body composition problem. A studentathlete who has increased resistance training to improve strength may also have a higher weight, but since this increased weight is likely to result from more muscle, this should be viewed as a positive change. The important consideration for weight is that it can be (and often is) misused as a measure of body composition, and this misuse can detract from the purpose of body composition assessment.

2. Comparing Body Composition Values with Other Athletes— Student-athletes often compare

body composition values with other student-athletes, but this comparison is not meaningful and it may drive a student-athlete to change body composition in a way that negatively impacts both performance and health. Health professionals involved in obtaining body composition data should be sensitive to the confidentiality of this information, and explain to each student-athlete that differences in height, age and gender are likely to result in differences in body composition, without necessarily any differences in performance. Strategies for achieving this include: • Obtaining body composition values with only one student-athlete at a time, to limit the chance that the data will be shared. • Giving student-athletes information on body composition using phrases such as “within the desirable range” rather than a raw value, such as saying “your body fat level is 18 percent.” • Providing athletes with information on how they have changed between assessments, rather than offering the current value. • Increasing the focus on muscle mass, and decreasing the focus on body fat. • Using body composition values as a means of helping to explain changes in objectively measured performance outcomes. 3. Seeking an Arbitrarily Low Level of Body Fat—Most studentathletes would like their body fat level to be as low as possible. However, student-athletes often try to seek a body fat level that is arbitrarily low and this can increase the frequency of illness, increase the risk of injury, lengthen the time

the student-athlete can return to training after an injury, reduce performance and increase the risk of an eating disorder. Body composition values should be thought of as numbers on a continuum that are usual for a sport. If a student-athlete falls anywhere on that continuum, it is likely that factors other than body composition (training, skills acquisition, etc.) will be the major predictors of performance success. 4. Frequency of Body Composition Assessment— Student-athletes who have frequent weight and/or skinfolds taken are fearful of the outcome, since the results are often (inappropriately) used punitively. Real changes in body composition occur slowly, so there is little need to assess student-athletes weekly, biweekly or even monthly. If body composition measurements are sufficient and agreed upon by all parties, measurement frequency of twice a year should be sufficient. In some isolated circumstances in which a student-athlete has been injured or is suffering from a disease state, it is reasonable for a physician to recommend a more frequent assessment rate to control for changes in lean mass. Studentathletes and/or coaches who desire more frequent body composition or weight measurement should shift their focus to assessments of objective performance-related measurers.

Summary The assessment of body composition can be a useful tool in helping the student-athlete and coach understand the changes that are occurring as a result of training and nutritional factors. However, the body composition measurement

Assessment of Body Composition For each student-athlete, there may be a unique optimal body composition for performance, for health and for self-esteem. However, in most cases, these three values are NOT identical. Mental and physical health should not be sacrificed for performance. An erratic or lost menstrual cycle, sluggishness or an obsession with achieving a number on a scale may be signs that health is being challenged.

Health Optimal

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Body

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Self-Esteem

Assessment of Body Composition process and the values obtained can be a sensitive issue for the studentathlete. A legitimate purpose for body composition assessment should dictate the use of these measurement techniques. Health professionals involved in obtaining body composition data should focus on using the same technique with the same prediction equations to derive valid comparative data over time. Institutions should have a protocol in place outlining the rationale for body composition measurements, who is allowed to measure the student-athlete, who is

permitted to discuss the results with the student-athlete and what frequency of body composition measurement is appropriate. The student-athlete should not feel forced or obligated to undergo body composition or weight measurement. Everyone involved directly or indirectly with body composition measurement should understand that inappropriate measurement and use of body composition data might contribute to the student-athlete experiencing unhealthy emotional

stress. This stress can lead to the development or enhancement of eating disorders in the studentathlete (see Guideline 2f). All coaches (sport or strength/ conditioning) should be aware of the sizable influence they may have on the behaviors and actions of their student-athletes. Many student-athletes are sensitive about body fat, so care should be taken to apply body composition measurement, when appropriate, in a way that enhances the studentathlete’s well-being.

References

1. Benardot D: Working with young athletes: Views of a nutritionist on the sports medicine team. Int. J. Sport Nutr. 6(2):110-120, 1996. 2. Boileau RA and Lohman TG. The measurement of human physique and its effect on physical performance. Orthopedic Clin. N. Am. 8:563581,1977. 3. Clarkson PM. Nutritional supplements for weight gain. Sports Science Exchange SSE#68(11): 1-18, 1998. 4. Clasey JL, Kanaley JA, Wideman L, Heymsfield SB, Teates CD, Gutgesell ME, Thorner MO, Hartman ML, and Weltman A. Validity of methods of body composition assessment in young and older men and women. J. Appl. Physiol. 86(5):1728-38, 1999.

7. Houtkooper LB and Going SB. Body composition: How should it be measured? Does it affect sport performance? Sports Science Exchange SSE#52(7):1-15, 1994. 8. Houtkooper LB, Going SB, Lohman TG, Roche AF, and Van Loan M. Bioelectrical impedance estimation of fat-free body mass in children and youth: a cross-validation study. J. Appl. Physiol. 72:366-373, 1992. 9. Jackson AS and Pollock ML. Generalized equations for predicting body density in men. Br. J. Nutr. 40:497-504, 1978. 10. Jackson AS, Pollock ML, and Ward A. Generalized equations for predicting body density of women. Med. Sci. Sports Exerc. 12:175-182, 1980.

5. Fleck SJ. Body composition of elite American athletes. Am. J. Sports Med. 11:398-403, 1983.

11. Lukaski HC. Methods for the assessment of human body composition—traditional and new. Am. J. Clin. Nutr. 46:537-56, 1987.

6. Heymsfield SB and Want Z. Measurement of total-body fat by underwater weighing: new insights and uses for old method. Nutrition 9:472473, 1993.

12. Malina RM and Bouchard C. Characteristics of young athletes. In: Growth, Maturation and Physical Activity. Champaign, IL: Human Kinetics Books, pp. 443-463, 1991.

13. Manore M, Benardot D, and Love P. Body measurements. In: Benardot D (Ed). Sports Nutrition: A Guide for Professionals Working with Active People Chicago, IL: American Dietetic Association, pp 70-93, 1993. 14. Melby CL and Hill JO. Exercise, macronutrient balance, and body weight regulation. Sports Science Exchange SSE#72(12): 1-16, 1999. 15. Thomas BJ, Cornish BH, Ward LC, and Jacobs A. Bioimpedance: is it a predictor of true water volume? Ann. N.Y. Acad. Sci. 873:89-93, 1999.

GUIDELINE 2f

Nutrition and Athletic Performance January 1986 • Revised June 2002, May 2009

Athletic performance and recovery from training are enhanced by attention to nutrient intake. Optimal nutrition for health and performance includes the identification of both the quantity and quality of food and fluids needed to support regular training and peak performance. As training demands shift during the year, athletes need to adjust their caloric intake and macronutrient distribution while maintaining a high nutrient-dense diet that supports their training and competition nutrient needs. The following key points summarize the impacts of training on energy, nutrient and fluid recommendations for competitive student-athletes as recommended by the American College of Sports Medicine (ACSM) and the American Dietetic Association (ADA). It is helpful to think of collegiate athletes’ training year as including three phases: base, competition and transition. During base training when training volume is high (practices are longer and/or more frequent), athletes’ energy needs are likely to be at their highest. A high-quality nutritional plan is key during this phase. Base training is also the best phase to experiment with and define event fueling and hydration strategies that can be

continued throughout the year. The competitive phase usually reflects a decrease in training volume, and perhaps higherintensity training sessions with extended periods of tapering leading up to competition and travel. During the competitive phase, athletes should adjust calorie and macronutrient intake to prevent unwanted weight gain, and learn how to eat before competition and while traveling, and how to adjust fluid needs based on environmental impacts. Athletes who consume a balanced, adequate diet will likely exhibit the best performance, and experience less illness during the competitive phase. The transition phase, during which athletes’ training volume and intensity are likely at their lowest, requires some attention to the prevention of unwanted changes in body weight (increased body fat or decreased muscle mass). During this phase, athletes may need to decrease total calorie intake and resist overindulging while still maintaining a nutrient-dense diet. Carbohydrate, the primary fuel for higher intensity activity, is required to replenish liver and glycogen stores and to prevent low blood sugar (hypoglycemia) during

training and performance. Carbohydrate intake has been well documented to have a positive impact on adaptation to training, performance and improved immune function. During base training, a daily intake of between 5 to 7 grams of carbohydrate per kilogram of body weight per day is advised. As training intensity and/or volume increase, carbohydrate need may easily exceed 10 grams of carbohydrate per kilogram of body weight. Athletes should begin to think about fueling for their next athletics activity immediately after the one they just completed. Recovery carbohydrate, to replace glycogen stores, can be calculated based on 1 to 1.2 grams of carbohydrate per kilogram of body weight and should be consumed immediately after training sessions

NCAA.org/nutritionandperformance

Nutrition and Athletic Performance longer than 90 minutes or highintensity, shorter-duration training sessions. Within two hours after training, additional carbohydrate will help continue glycogen repletion. The U.S. Dietary Guidelines and experts in performance nutrition recommend that athletes focus their food choices on less-refined types of carbohydrate, as these contain essential micronutrients vital to health and performance. Whole grains, breads, pasta, whole fruits and vegetables are excellent sources of high-quality carbohydrate.

Available online at NCAA.org/ health-safety.

Protein requirements are slightly higher in both endurance (1.2 to 1.4 grams per kilogram body weight) and strength-training student-athletes (1.6 to 1.7 grams per kilogram body weight), above the typical recommended daily intake (0.8 grams per kilogram body weight). Fortunately, the higher intakes recommended for athletes are easily achieved in a well-balanced diet without the use of additional supplements. Fat intake is an important source of essential fatty acids and carrier for fat-soluble vitamins necessary for optimal physiological function. During prolonged, lower-intensity training, fats are a major energy contributor and are stored in muscle as triglyceride for use during activity. Dietary intake is suggested to be between 20 to 35 percent of total daily caloric intake. Diets low in fat intake can negatively impact training, nutrient density of the diet and the ability to consistently improve performance.

In general, vitamin and mineral supplements are not required if a student-athlete is consuming adequate energy from a variety

of foods to maintain body weight. However, the risk of micronutrient deficiencies is greatest in studentathletes who are restricting calories, engaging in rapid weightloss practices or eliminating specific foods or food groups from their diet. A multivitamin providing not more than 100 percent of the daily recommended intake can be considered for these student-athletes. Female studentathletes are especially prone to deficiencies in calcium and iron due to the impacts of regular menstrual cycles, avoidance of animal products and/or energy restriction. The diets and iron status of endurance athletes and vegetarians (especially females) should be evaluated. However, megadoses of specific vitamins or minerals (10 to 100 times the dose of daily requirements) are not recommended. Hydration status impacts health and performance. Athletes should consume fluids throughout their day (water, low fat milk, 100 percent fruit juices) and before, during and after training. Fluids containing electrolytes and carbohydrates are a good source of fuel and re-hydration. Fluids containing questionable supplement ingredients and high levels of caffeine or other stimulants may be detrimental to the health of the competitive athlete and are not effective forms of fuel or hydration. Adequate overall energy intake spread out across the day is important for all student-athletes. Insufficient energy intakes (due to skipped meals or dieting) will have a rapid negative impact on training and performance, and over time, on bone, immune function and injury risk. Inadequate energy intakes increase fatigue, deplete muscle

Nutrition and Athletic Performance glycogen stores, increase the risk of dehydration, decrease immune function, increase the risk of injury and result in unwanted loss of muscle mass. A low caloric intake in female student-athletes can lead to menstrual dysfunction and decreased bone mineral density. The maintenance or attainment of an ideal body weight is sportspecific and represents an important part of a nutritional program. However, student-athletes in certain sports face a difficult paradox in their training/nutrition regimen, particularly those competing in “weight class” sports (e.g., wrestling, rowing), sports that favor those with lower body weight (e.g., distance running, gymnastics), sports requiring student-athletes to wear body contour-revealing clothing (track, diving, swimming, volleyball) and sports with subjective judging related to “aesthetics” (gymnastics, diving). These student-athletes are encouraged to eat to provide the necessary fuel for performance, yet they often face self- or teamimposed weight restrictions. Emphasis on low body weight or low body fat may benefit performance only if the guidelines are realistic, the calorie intake is reasonable and the diet is nutritionally well-balanced. The use of extreme weight-control measures can jeopardize the health of the student-athlete and possibly trigger behaviors associated with eating disorders. NCAA studies have shown that at least 40 percent of member institutions reported at least one case of anorexia nervosa or bulimia nervosa in their athletics programs. Once identified, these individuals should be referred for medical evaluation and psychological and nutritional therapy.

A more prevalent issue is the large number of sub-clinical or chronically dieting athletes. Department-wide efforts to educate staff and student-athletes should include addressing the negative impacts of under-fueling and weight/food preoccupation on the athletes’ performance and overall well-being. Although dysfunctional eating is much more prevalent in women (approximately 90 percent of the reports in the NCAA studies were in women’s sports), dysfunctional eating also occurs in men. Female athletes who miss three or more menstrual cycles in a year, are preoccupied with weight, experience rapid changes in body weight, avoid eating with others, or are overfocused on shape and food are exhibiting warning signs worth addressing, if prevention of eating disorders is desired. The medical examination and updated history (Bylaw 17.1.5) is an opportunity to assess athletes for these risk factors and refer them to appropriate professionals for further evaluation and diagnosis. Eating disorders are often an expression of underlying emotional distress that may have developed long before the individual was involved in athletics. Eating disorders can be triggered in psychologically vulnerable individuals by a single event or comments (such as offhand remarks about appearance, or constant badgering about a student-athlete’s body weight, body composition or body type) from a person important to the individual. Coaches, athletic trainers, sport dietitians and supervising physicians must be watchful for student-athletes at higher risk for eating disorders. Disordered eating can lead to dehydration, resulting in loss of muscular strength and endurance,

Eating disorders are often an expression of underlying emotional distress that may have developed long before the individual was involved in athletics. Eating disorders can be triggered in psychologically vulnerable individuals by a single event or comments (such as offhand remarks about appearance, or constant badgering about a student-athlete’s body weight, body composition or body type) from a person important to the individual.

Nutrition and Athletic Performance decreased aerobic and anaerobic power, loss of coordination, impaired judgment, and other complications that decrease performance and impair health. These symptoms may be readily apparent or may not be evident for an extended period of time. Many student-athletes have performed successfully while experiencing an eating disorder. Therefore, diagnosis of this problem should not be based entirely on a decrease in athletic performance. Body composition and body weight can affect exercise performance but should not be used as the main criteria for participation in sports. Decisions regarding weight loss should be based on the following recommendations to reduce the risk of disordered eating. 1. Frequent weigh-ins (either as a team or individually) are discouraged unless part of strategies outlined in Guideline 2c. 2. Weight loss (fat loss) should be addressed during base or transition phases. 3. Weight-loss goals should be determined by the student-athlete and medical and nutritional personnel, with consultation from the coach. 4. Weight-loss plans should be individualized and realistic.

For each student-athlete, there may be a unique optimal body composition for performance, for health and for self-esteem. However, in most cases, these three values are NOT identical. Mental and physical health should not be sacrificed for performance. An erratic or lost menstrual cycle, sluggishness or an obsession with achieving a number on a scale may be signs that a student-athlete's health is being challenged.

Nutrition and Athletic Performance References

1. Nutrition and Athletic Performance. American College of Sports Medicine, American Dietetic Association, and Dietitians of Canada, Joint Position Stand, Medicine and Science in Sports and Exercise. 109:3:509-527, March 2009 2. The Female Athlete Triad. American College of Sports Medicine (ACSM) Position Stand, Medicine and Science in Sports and Exercise, 39:10: 1-10 2007. 3. Exercise and Fluid Requirements. American College of Sports Medicine (ACSM) Position Stand. 2007 4. Brownell KD, Rodin J, Wilmore JH: Eating, Body Weight, and Performance in Athletes: Disorders of Modern Society Malvern, PA: Lea and Febiger, 1992. 5. Dale, KS, Landers DM. Weight control in wrestling: eating disorders or disordered eating? Medicine and Science in Sports and Exercise 31:1382-1389, 1999. 6. Dick RW: Eating disorders in NCAA athletics programs. Athletic Training 26:136-140, 1991. 7. Sandborn CF, Horea M, Siemers BJ, Dieringer KI. Disordered eating and the female athlete triad. Clinics in Sports Medicine:19:199-213, 2000.

GUIDELINE 2g

Dietary Supplements January 1990 • Revised June 2004, June 2009

Nutritional and dietary supplements are marketed to student-athletes to improve performance, recovery time and muscle-building capability. Many student-athletes use nutritional supplements despite the lack of proof of effectiveness. In addition, such substances are expensive and may potentially be harmful to health or performance. Of greater concern is the lack of regulation and safety in the manufacture of dietary supplements. Many compounds obtained from specialty “nutrition” stores and mail-order businesses may not be subject to the strict regulations set by the U.S. Food and Drug Administration. Therefore, the contents of many of these compounds are not represented accurately on the list of ingredients and may contain impurities or banned substances, which may cause a student-athlete to test positive. Positive drug-test appeals based on the claim that the studentathletes did not know the substances they were taking contained banned drugs have not been successful. Student-athletes should be instructed to consult with the institution's sports medicine staff before taking ANY nutritional supplement. Member institutions are restricted in the providing of nutritional supplements – see NCAA bylaws for divisional regulations.

It is well known that a highcarbohydrate diet is associated with

improved performance and enhanced ability to train. Carbohydrates in the form of glycogen are the body's main fuel for high-intensity activity. A large number of student-athletes only consume 40 to 50 percent of their total calories from carbohydrates, versus the recommended 55 to 65 percent for most people (about 5 to 10 gm/kg body weight). The lower end of the range should be ingested during regular training; the high end during intense training. High-carbohydrate foods and beverages can provide the necessary amount of carbohydrate for the high caloric demand of most sports to optimize performance. Low-carbohydrate diets are not advantageous for athletes during intense training and could result in a significantly reduced ability to perform or train by the end of an intense week of training. When the levels of carbohydrate are reduced, exercise intensity and length of activity decreases, and fatigue rapidly increases. A high-carbohydrate diet

consisting of complex carbohydrates, fruits, vegetables, low-fat dairy products and whole grains (along with adequate protein) is the optimal diet for peak performance. (See Guideline 2f, Nutrition and Athletic Performance.) Protein and amino acid supplements are popular with bodybuilders and strength-training student-athletes. Although protein is needed to repair and build muscles after strenuous training, most studies have shown that student-athletes ingest a sufficient amount without supplements. The recommended amount of protein in the diet should be 12 to 15 percent of total energy intake (about 1.4 to 1.6 gm/kg of body weight) for all types of student-athletes. Although selected amino acid supplements are purported to increase the production of anabolic hormones, studies using manufacturerrecommended amounts have not found increases in growth hormone or muscle mass. Ingesting high amounts of single amino acids is

Dietary Supplements contraindicated because they can affect the absorption of other essential amino acids, produce nausea, and/or impair kidney function and hydration status. Other commonly advertised supplements are vitamins and minerals. Most scientific evidence shows that selected vitamins and minerals will not enhance performance provided no deficiency exists. Some vitamins and minerals are marketed to student-athletes for other benefits. For example, the antioxidants, vitamins E and C, and betacarotene, are used by many student-athletes because they believe that these antioxidants will protect them from the damaging effects of aerobic exercise. Although such exercise can cause muscle damage, studies have found that training will increase the bodyâ&#x20AC;&#x2122;s natural antioxidant defense system so that mega doses of antioxidants may not be needed. Supplementation in high dosages of antioxidants, such as vitamins E and C, and beta-carotene, could disrupt the normal balance of these compounds and the balance of free radicals in the body and cause more harm than good. (American Council on Science and Health) The mineral chromium has been suggested to increase muscle mass and decrease fat; these claims have little, if any, credible support. In fact, the Federal Trade Commission has declared such claims to be unsubstantiated and deceptive. Similarly, magnesium is purported, but not proven, to prevent cramps. To obtain necessary vitamins and minerals, student-athletes should eat a wide variety of foods because not all vitamins and minerals are found in every food.

Other substances naturally occurring in foods, such as carnitine, herbal extracts and special enzyme formulations, do not provide any benefit to performance. The high-protein diet has received recent attention, but data showing that this diet will enhance performance are weak. High-protein diets are discouraged by most nutrition experts due to increased stress placed on the kidneys. Mild to severe stomach cramping and diarrhea, dehydration, and gout have been

associated with use of certain amino acid supplements. Creatine has been found in some laboratory studies to enhance short-term, high-intensity exercise capability, delay fatigue on repeated bouts of such exercise and increase strength. Several studies have contradicted these claims, and, moreover, the safety of creatine supplements has not been verified. Weight gains of one to three kilograms per week have been found in creatine users, but the cause is unclear. Many other â&#x20AC;&#x153;high-techâ&#x20AC;? nutritional

Dietary Supplements or dietary supplements may seem to be effective at first, but this is likely a placebo effect — if studentathletes believe these substances will enhance performance, they may train harder or work more efficiently. Ultimately, most nutritional supplements are ineffective, costly and unnecessary. Student-athletes should be aware that nutritional supplements are not limited to pills and powders; “energy” drinks that contain stimulants are popular. Many of these contain large amounts of either caffeine or other stimulants, both of which can result in a positive drug test. Student-athletes should be wary of drinks that promise an “energy boost,” because they may contain banned stimulants. In addition, the use of stimulants while exercising can increase the risk of heat illness. Student-athletes should be provided accurate and sound information on nutritional supplements. It is not

worth risking eligibility for products that have not been scientifically proven to improve performance and may contain banned substances. Member institutions should review NCAA Bylaw 16.5.2, educational columns and interpretations for guidance on restrictions on providing supplements to student-athletes. The NCAA subscribes to the Resource Exchange Center (REC). The REC (www.drugfreesport.com/ rec) provides accurate information on performance-enhancing drugs, dietary supplements, medications, new ingredients and validity of product claims, and whether a substance is banned by the NCAA. This service is provided 24 hours a day via a password-protected website for all NCAA member schools and their student-athletes and athletics personnel. To access the REC, go to www.drugfreesport. com/rec. The password is ncaa1, ncaa2, or ncaa3, depending on your divisional classification.

Caution: “Nutritional/ dietary supplements may contain NCAA banned substances. The U.S. Food and Drug Administration does not strictly regulate the supplement industry; therefore, purity and safety of nutritional/dietary supplements cannot be guaranteed. Impure supplements may lead to a positive NCAA drug test. The use of supplements is at the student-athlete’s own risk. Studentathletes should contact their institution’s team physician or athletic trainer for further information.”

References

1. Burke L: Practical issues in nutrition for athletes. Journal of Sports Sciences 13:S83-90, 1995. 2. Clarkson PM, Haymes EM: Trace Mineral Requirements for Athletes. International Journal of Sport Nutrition 4:104-19, 1994. 3. Clarkson PM: Micronutrients and exercise: Antioxidants and minerals. Journal of Sports Sciences 12:S11-24, 1995. 4. American College of Sports Medicine. The physiological and health effects of oral creatine supplementation. Medicine

and Science in Sports and Exercise. 32 (3): 706-717, 2000. 5. Lemon PWR: Do athletes need more dietary protein and amino acids? International Journal of Sport Nutrition 5:S39-61, 1995. 6. Volek JS, Kraemer WJ: Creatine supplementation: Its effect on human muscular performance and body composition. Journal of National Strength and Conditioning Research 10:200-10, 1996. 7. Williams C: Macronutrients and performance. Journal of Sports Sciences 13:S1-10, 1995.

8. The National Center for Drug Free Sport, Inc., 810 Baltimore, Suite 200, Kansas City, Missouri. 64105; 816/4748655. 9. ACSM JOINT POSITION STATEMENT, Nutrition and Athletic Performance, 2000. Available at www. acsm-msse.org. 10. Nutritional Supplements, The NCAA News, April 15, 2005. 11. IOC study, 2001. 12. HFL study, 2007.

GUIDELINE 2h

“Burners” (Brachial Plexus Injuries) June 1994 • Revised June 2003

“Burners” or “stingers” are so named because the injuries can cause a sudden pain and numbness along the forearm and hand. The more formal medical terminology is transient brachial plexopathy or an injury to the brachial plexus. A brachial plexus injury may also involve injury to a cervical root. An injury to the spinal cord itself is more serious and frequently does not fall under this category of injury, although it shares certain symptoms; therefore, spinal cord injuries should be ruled out when diagnosing stingers. The majority of stingers occur in football. Such injuries have been reported in 52 percent of college football players during a single season. As many as 70 percent of college football players have experienced stingers. Stingers also can occur in a variety of other sports, including basketball, ice hockey, wrestling and some field events in track.

Mechanism The most common mechanism for stingers is head movement in an opposite direction from the shoulder either from a hit to the head or downward traction of the shoulder. This can stretch the nerve roots on the side receiving the blow (traction), or compress or pinch those

on the opposite side. Contact to the side of the neck may cause a direct contusion to the brachial plexus. In football, improper blocking and tackling techniques may result in a brachial plexus injury. Coaches, parents and student-athletes should be cautioned regarding the consequences of improper techniques, which may result in cervical spine injuries or trauma to the brachial plexus.

Symptoms and Severity Student-athletes who suffer burners may be unable to move the affected arm from their side and will complain of burning pain, and potentially, numbness traveling from the injured side of the neck through the shoulder down the arm and forehand, and sometimes into the hand. Weakness may be present in the muscles of the shoulder, elbow and hand. Brachial plexus injuries can be classified into three categories. The mildest form (Grade 1) are neuropraxic injuries that involve demyelination of the axon sheath without intrinsic axonal disruption. Compete recovery typically occurs in a few seconds to days. Grade 1 injuries are the most common in athletics. Grade 2 injuries involve axonotmesis or disruption of the axon and myelin sheath with pres-

The majority of stingers occur in football. Such injuries have been reported in 52 percent of college football players during a single season. As many as 70 percent of college football players have experienced stingers. Stingers also can occur in a variety of other sports, including basketball, ice hockey, wrestling and some field events in track.

“Burners” (Brachial Plexus Injuries)

All athletes sustaining burners or stingers should undergo a physical rehabilitation program that includes neck and trunk strengthening exercises. The fit of shoulder pads should be re-checked and consideration of other athletic protective equipment, such as neck rolls and/or collars, should be given. The athlete’s tackling techniques should be reviewed.

ervation of the epineurium, perineurium, and endoneurium, which can serve as the conduit for the regenerating axon as it regrows at 1 to 7 millimeters per day. Weakness can last for weeks but full recovery typically occurs. Grade 3 injuries, neurotmesis or complete nerve transections are rare in athletes. Surgical repair of the nerve is required in these cases and complete recovery may not occur. These classifications have more meaning with regard to anticipated recovery of function than a grading on the severity of symptoms at the time of initial injury.

Treatment and Return to Play Burners and stingers typically result in symptoms that are sensory in nature, frequently involving the C5 and C6 dermatomes. All athletes sustaining burners should be removed from competition and examined thoroughly for injury to the cervical spine and shoulder. All cervical roots should be assessed for motor and sensory function. If symptoms clear within seconds to several minutes and are not associated with any neck pain, limitation of neck movement or signs of shoulder subluxation or dislocation, the athlete can safely return to competition. It is important to re-examine the athlete after the game and for a few successive days to detect any reoccurrence of weakness or alteration in sensory exam. If sensory complaints or weakness persists for more than a few minutes, a full medical evaluation with radiographs and consideration for a MRI should be done to rule out cervical disk or other compressive pathology. If symptoms persist for more than 2 to 3 weeks, an EMG may be helpful in assessing the

extent of injury. However, an EMG should not be used for return-toplay criteria, as EMG changes may persist for several years after the symptoms have resolved. Shoulder injuries (acromioclavicular separation, shoulder subluxation or dislocation, and clavicular fractures) should be considered in the differential diagnosis of the athlete with transient or prolonged neurologic symptoms of the upper extremity. Any injured athlete who presents with specific cervical-point tenderness, neck stiffness, bony deformity, fear of moving his/her head and/ or complains of a heavy head should be immobilized on a spine board (as one would for a cervical spine fracture) and transported to a medical facility for a more thorough evaluation. Bilateral symptoms indicate that

“Burners” (Brachial Plexus Injuries) the cord itself has been traumatized and may suggested transient quadriplegia. These athletes should also be immobilized and transported to a medical facility for a more thorough evaluation. All athletes sustaining burners or stingers should undergo a physical rehabilitation program that includes neck and trunk strengthening exercises. The fit of shoulder pads should be re-checked and consideration of other athletic protective equipment, such as neck rolls and/ or collars, should be given. The athlete’s tackling techniques should be reviewed. Stinger assessment should be part of the student-athletes’ preseason physical and mental history (see handbook Guideline No. 1b) so that these “at-risk” athletes can be instructed in a prevention preventative exercise program and be provided with proper protective equipment.

Recurrent Burners Recurrent burners may be common; 87 percent of athletes in one study had experienced more than one. Medical personnel should pay special attention to this condition.

Although rare, risk of permanent nerve injury exists for those with recurrent burners. Therefore, participants should report every occurrence to their certified athletic trainers or team physician. Any player with persistent pain, burning, numbness and/or weakness (lasting longer than two minutes) should be held out of competition and referred to a physician for further evaluation.

A Word of Caution Management of the student-athlete with recurrent burners can be difficult. There are no clear guidelines concerning return to play. Although some risk of permanent nerve injury exists, a review of the literature shows this risk to be small for those with recurrent episodes. The most important concern for student-athletes with recurrent burners is to stress the importance of reporting all symptoms to the attending medical personnel so that a thorough physical examination, with particular attention to strength and sensory changes, can be obtained. Any worsening of symptoms should provoke a more thorough evaluation.

References

1. Meyer S, Schulte K, et al: Cervical Spinal Stenosis and Stingers in Collegiate Football Players. American Journal of Sports Medicine 22(2):158166, 1994. 2. Torg J, et al: Cervical Cord Neuropraxia: Classification Pathomechanics, Morbidity and Management Guidelines. Journal of Neurosurgery 87:843-850, 1997. 3. Feinberg J, et al: Peripheral Nerve Injuries in the Athlete. Sports Medicine 12(6):385-408, 1997. 4. Meyer S, et al: Cervical Spinal Stenosis and Stingers in Collegiate

Football Players. American Journal of Sports Medicine 22(2), 1994. 5. Cantu R: Stingers, Transient Quadriplegia, and Cervical Spinal Stenosis: Return-to-Play Criteria. Medicine and Science of Sports and Exercise 7(Suppl):S233-235, 1997. 6. Levitz C, et al: The Pathomechanics of Chronic Recurrent Cervical Nerve Root Neuropraxia, the Chronic Burner Syndrome. American Journal of Sports Medicine 25(1), 1997. 7. Castro F, et al: Stingers, the Torg Ratio, and the Cervical Spine. American Journal of Sports Medicine 25(5), 1997.

8. Weinstein S: Assessment and Rehabilitation of the Athlete with a Stinger. A Model for the Management of Non-catastrophic Athletic Cervical Spine Injury. Clinic and Sports Medicine 17(1), 1998. 9. Shannon B, Klimkiewicz J, Cervical Burners in the Athlete. Clinic and Sports Medicine 21(1):29-35 January 2002. 10. Koffler K, Kelly J, Neurovascular Trauma in Athletes. Orthop Clin N Am 33: 523-534(2002). 11. Feinberg J, Burners and Stingers, Phys Med Rehab N Am 11(4): 771-783 Nov 2000.

GUIDELINE 2i

Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete June 1994 • Revised July 2004, 2009, July 2010

Estimates suggest that 1.6-1.8 million concussions occur from participation in sports- and recreation-related activities every year (see reference No. 18). These injuries are often difficult to detect, with athletes often underreporting their injury, minimizing their importance or not recognizing that an injury has occurred. At the college level, these injuries are more common in certain sports, such as football, ice hockey, men’s and women’s soccer, and men’s lacrosse. However, they also

account for a significant percentage of injuries in men’s and women’s basketball, women’s lacrosse, and other sports traditionally considered “noncontact.” The incidence in helmeted versus nonhelmeted sports is also similar. In the years 2004 to 2009, the rate of concussion during games per 1,000 athlete exposures for football was 3.1, for men’s lacrosse 2.6, for men’s ice hockey 2.4, for women's ice hockey 2.2, for women's soccer 2.2, for wrestling 1.4, for men's

soccer 1.4, for women’s lacrosse 1.2, for field hockey 1.2, for women’s basketball 1.2, and for men’s basketball 0.6, accounting for between 4 and 16.2 percent of the injuries for these sports as reported by the NCAA Injury Surveillance Program by the Datalys Center. Assessment and management of concussive injuries, and return-toplay decisions remain some of the most difficult responsibilities facing the sports medicine team. There are potentially serious complications of multiple or severe concussions, including second impact syndrome, postconcussive syndrome, or post-traumatic encephalopathy. Though there is some controversy as to the existence of second impact syndrome, in which a second impact with potentially catastrophic consequences occurs before the full recovery after a first insult, the risks include severe cognitive compromise and death. Other associated injuries that can occur in the setting of concussion include seizures, cervical spine injuries, skull fractures and/or intracranial bleed. Due to the serious nature of mild traumatic brain injury, and these serious potential complications, it is

Concussion or Mild Traumatic Brain Injury imperative that the health care professionals taking care of athletes are able to recognize, evaluate and treat these injuries in a complete and progressive fashion. In April 2010, the NCAA Executive Committee adopted a policy that requires NCAA institutions to have a concussion management plan on file. (See information box on page 55.) Concussion or mild traumatic brain injury (mTBI) has been defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.” Although concussion most commonly occurs after a direct blow to the head, it can occur after a blow elsewhere that is transmitted to the head. Concussions can be defined by the clinical features, pathophysiological changes and/or biomechanical forces that occur, and these have been described in the literature. The neurochemical and neurometabolic changes that occur in concussive injury have been elucidated, and exciting research is underway describing the genetic factors that may play a role in determining which individuals are at an increased risk for sustaining brain injury. Most commonly, concussion is characterized by the rapid onset of cognitive impairment that is self limited and spontaneously resolves. The acute symptoms of concussion, listed below, are felt to reflect a functional disturbance in cognitive function instead of structural abnormalities, which is why diagnostic tests such as magnetic resonance imaging (MRI) and computerized tomography (CT) scans are most often normal. These studies may have their role in assessing and evaluating the head-injured athlete whenever there is concern for the associated

injuries of skull fracture, intracranial bleeding and seizures, when there is concern for structural abnormalities or when the symptoms of an athlete persist or deteriorate. Concussion is associated with clinical scenarios that often clear spontaneously, and may or may not be associated with loss of consciousness (LOC). The sideline evaluation of the brain-injured athlete should include an assessment of airway, breathing and circulation (ABCs), followed by an assessment of the cervical spine and skull for associated injury. The sideline evaluation should also include a neurological and mental status examination and some form of brief neurocognitive testing to assess memory function and attention. This can be in the form of questions regarding the particular practice or competition, previous game results, and remote and recent memory, and questions to test the athlete’s recall of words, months of the year backwards and calculations. Special note should be made regarding the presence and duration of retrograde or anterograde amnesia, and the presence and duration of confusion. A timeline of injury and the presence of symptoms should be

noted. These sideline tests should be performed and repeated as necessary, but do not take the place of other comprehensive neuropsychological tests. Once an injury occurs and an initial assessment has been made, it is important to determine an initial plan of action, which includes deciding on whether additional referral to a physician and/or emergency department should take place, and determining the followup care. The medical staff should also determine whether additional observation or hospital admission should be considered. Follow-up care and instructions should be given to the athlete, and ensuring that they are not left alone for an initial period of time should be considered. Athletes should avoid alcohol or other substances that will impair their cognitive function, and also avoid aspirin and other medications that can increase their risk of bleeding. As mentioned previously, conventional imaging studies such as MRI and CT scans are usually normal in mTBI. However, these studies are considered an adjunct when any structural lesion, such as an intracranial bleed or fracture, is suspected. If an athlete

Table 1

SIGNS AND SYMPTOMS OF mTBI Loss of consciousness (LOC) Confusion Post-traumatic amnesia (PTA) Retrograde amnesia (RGA) Disorientation Delayed verbal and motor responses Inability to focus Headache Nausea/Vomiting Excessive drowsiness

Visual Disturbances (Photophobia, blurry Phono/ photophobia vision, double vision) Disequilibrium Feeling “in a fog,” “zoned out” Vacant stare Emotional lability Dizziness Slurred/incoherent speech

Concussion or Mild Traumatic Brain Injury experiences prolonged loss of consciousness, confusion, seizure activity, focal neurologic deficits or persistent clinical or cognitive symptoms, then additional testing may be indicated. There are several grading systems and return-to-play guidelines in the literature regarding concussion in sport (AAN, Torg, Cantu). However, there may be limitations because they presume that LOC is associated with more severe injuries. It has been demonstrated that LOC does not correlate with severity of injury in patients presenting to an emergency department with closed head injury, and has also been demonstrated in athletes with concussion (Lovell ‘99). It has been further demonstrated that retrograde amnesia (RGA), post-traumatic amnesia (PTA), and the duration of confusion and mental status changes are more sensitive indicators of injury severity (Collins ‘03), thus an athlete with these symptoms should not be allowed to return to play during the same day. These athletes should not return to any participation until cleared by a physician. More recent grading systems have been published that attempt to take into account the expanding research in the field of mTBI in athletes. Though it is useful to become familiar with these guidelines, it is important to remember that many of these injuries are best treated in an

1. NCAA Concussion Fact Sheets and Video for Coaches and Student-Athletes Available at www.NCAA.org/health-safety. 2. Heads Up: Concussion Tool Kit CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm. 3. Heads Up Video NATA. Streaming online at www.nata.org/consumer/headsup.htm.

individual fashion (Cantu ‘01, Zurich Conference, NATA ‘04).

needed to understand the complete role of neuropsychological testing.

Several recent publications have endorsed the use of neurocognitive or neuropsychological testing as the cornerstone of concussion evaluation. These tests provide a reliable assessment and quantification of brain function by examining brain-behavior relationships. These tests are designed to measure a broad range of cognitive function, including speed of information processing, memory recall, attention and concentration, reaction time, scanning and visual tracking ability, and problem solving ability. Several computerized versions of these tests have also been designed to improve the availability of these tests, and make them easier to distribute and use. Ideally, these tests are performed before the season as a “baseline” with which post-injury tests can be compared. Despite the utility of neuropsychological test batteries in the assessment and treatment of concussion in athletes, several questions remain unanswered. Further research is

Given these limitations, it is essential that the medical care team treating athletes continue to rely on its clinical skills in evaluating the head-injured athlete to the best of its ability. It is essential that no athlete be allowed to return to participation when any symptoms persist, either at rest or during exertion. Any athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulties with memory function should not be allowed to return to play during the same day of competition. The duration of time that an athlete should be kept out of physical activity is unclear, and in most instances, individualized return-toplay decisions should be made. These decisions will often depend on the clinical symptoms, previous history of concussion and severity of previous concussions. Additional factors include the sport, position, age, support system for the athlete and the overall “readiness” of the athlete to return to sport.

Table 2

SYMPTOMS OF POST-CONCUSSION SYNDROME

Loss of intellectual capacity Poor recent memory Personality changes Headaches Dizziness Lack of concentration Poor attention

Fatigue Irritability Phono/photophobia Sleep disturbances Sleep disturbances Depressed mood Anxiety

Once an athlete is completely asymptomatic, the return-to-play progression should occur in a stepwise fashion with gradual increments in physical exertion and risk of contact. After a period of remaining asymptomatic, the first step is an “exertional challenge” in which the athlete exercises for 15 to 20 minutes in an activity such as biking or running in which he/she increases his/her heart rate and

Concussion or Mild Traumatic Brain Injury breaks a sweat. If he/she does not experience any symptoms, this can be followed by a steady increase in exertion, followed by return-tosport-specific activities that do not put the athlete at risk for contact. Examples include dribbling a ball or shooting, stickwork or passing, or other agilities. This allows the athlete to return to the practice setting, albeit in a limited role. Finally, the athlete can be progressed to practice activities with limited contact and finally full contact. How quickly one moves through this progression remains controversial.

The NCAA Executive Committee adopted (April 2010) the following policy for institutions in all three divisions. “Institutions shall have a concussion management plan on file such that a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussions. Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or his or her designee according to the concussion management plan. “In addition, student-athletes must 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. During the review and signing process, student-athletes should be presented with educational material on concussions.”

References

1. Cantu RC: Concussion severity should not be determined until all postconcussion symptoms have abated. Lancet 3:437-8, 2004. 2. Cantu RC: Recurrent athletic head injury: risks and when to retire. Clin Sports Med. 22:593-603, 2003. 3. Cantu RC: Post traumatic (retrograde/ anterograde) amnesia: pathophysiology and implications in grading and safe return to play. Journal of Athletic Training. 36(3): 244-8, 2001. 4. Centers for Disease Control and Prevention. Sports-related recurrent brain injuries: United States. MMWR Morb Mortal Wkly Rep 1997; 46:224227. 5. Collie A, Darby D, Maruff P: Computerized cognitive assessment of athletes with sports related head injury. Br. J Sports Med 35(5):297-302, 2001. 6. Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J: Onfield predictors of neuropsychological and symptom deficit following sportsrelated concussion. Clin J Sport Med 2003; 13:222-229. 7. Collins MW, Grindel SH, Lovell MR et al: Relationship Between Concussion

and Neuropsychological Performance in College Football Players. JAMA 282:964-970, 1999. 8. Guskiewicz KM, Bruce SL, Cantu R, Ferrara MS, Kelly JP, McCrea M, Putukian M, McLeod-Valovich TC; National Athletic Trainers’ Association Position Statement: Management of Sport-related Concussion: Journal of Athletic Training. 39(3): 280-297, 2004. 9. Guskiewicz KM: Postural stability assessment following concussion: One piece of the puzzle. Clin J Sport Med 2001; 11:182-189. 10. Hovda DA, Lee SM, Smith ML et al: The Neurochemical and metabolic cascade following brain injury: Moving from animal models to man. J Neurotrauma 12(5):143-146, 1995. 11. Johnston K, Aubry M, Cantu R et al: Summary and Agreement Statement of the First International Conference on Concussion in Sport, Vienna 2001, Phys & Sportsmed 30(2):57-63, 2002. 12. Lovell MR, Iverson GL, Collins MW et al: Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med 9:193198, 1999.

13. Makdissi M, Collie A, Maruff P et al: Computerized cognitive assessment of concussed Australian Rules footballers. Br. J Sports Med 35(5):354-360, 2001. 14. McCrea M: Standardized mental status assessment of sports concussion. Clin J Sport Med 11(3):176-181, 2001. 15. McCrea M, Hammeke T, Olsen G, Leo , Guskiewicz K: Unreported concussion in high school football players. Clin J Sport Med 2004;14:1317. 16. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Concensus Statement on Concussion in Sport: the Third International Conference on Concussion in Sport. Zurich, Switzerland, 2008. Br J Sports Med 2009;43:i76-i84. 17. Torg JS: Athletic Injuries to the Head, Neck, and Face. St. Louis, Mosby-Year Book, 1991. 18. Langlois JA, Rutland-Brown LV, Wald MM. The Epidemiology and Impact of Traumatic Brain Injury. J Head Trauma Rehabil. 2006; 21:375-8.

Concussion or Mild Traumatic Brain Injury In Addition to the Executive Committee Policy Requirements, Additional Best Practices for a Concussion Management Plan Include, but are not Limited to: 1. Although sports currently have rules in place, athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced.

for each student-athlete before the first practice in the sports of baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse, pole vaulting, rugby, soccer, softball, water polo and wrestling, at a minimum. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment should consist of one or more of the following areas of assessment.

2. Institutions should have on file and annually update an emergency action plan for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to, concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g., asthma), and sickle cell trait collapses. All athletics healthcare providers and coaches should review and practice the plan at least annually.

1) At a minimum, the baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments [e.g., SAC; SCAT; SCAT II; Balance Error Scoring System (BESS)].

3. Institutions should have on file an appropriate healthcare plan that includes equitable access to athletics healthcare providers for each NCAA sport.

2) Additionally, neuropsychological testing (e.g., computerized, standard paper and pencil) has been shown to be effective in the evaluation and management of concussions. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist who is in the best position to interpret NP tests by virtue of background and training. However, there may be situations in which neuropsychologists are not available and a physician experienced in the use and interpretation of such testing in an athletic population may perform or interpret NP screening tests.

d. The student-athlete should receive serial monitoring for deterioration. Athletes should be provided with written instructions upon discharge, preferably with a roommate, guardian or someone who can follow the instructions. e. The student-athlete should be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return-to-play should follow a medically supervised stepwise process. 6. Institutions should document the incident, evaluation, continued management and clearance of the student-athlete with a concussion.

For references, visit www.NCAA.org/health-safety.

GUIDELINE 2j

Skin Infections in Athletics July 1981 • Revised June 2008

Skin infections may be transmitted by both direct (person to person) and indirect (person to inanimate surface to person) contact. Infection control measures, or measures that seek to prevent the spread of disease, should be used to reduce the risks of disease transmission. Efforts should be made to improve student-athlete hygiene practices, to use recommended procedures for cleaning and disinfection of surfaces, and to handle blood and other bodily fluids appropriately. Suggested measures include: promotion of hand and personal hygiene practices; educating athletes and athletics staff; ensuring recommended procedures for cleaning and disinfection of hard surfaces are followed; and verifying clean up of blood and other potentially infectious materials is done, according to the Occupational Health and Safety Administration (OSHA) Blood-borne Pathogens Standard #29 CFR 1910.1030. Categories of skin conditions and examples include: 1. Bacterial skin infections a. impetigo; b. erysipelas; c. carbuncle; d. staphylococcal disease, MRSA; e. folliculitis (generalized); f. hidradentitis suppurativa; 2. Parasitic skin infections a. pediculosis;

b. scabies; 3. Viral skin infections a. herpes simplex; b. herpes zoster (chicken pox); c. molluscum contagiosum; and 4. Fungal skin infections a. tinea corporis (ringworm). Note: Current knowledge indicates that many fungal infections are easily transmitted by skin-to-skin contact. In most cases, these skin conditions can be covered with a securely attached bandage or nonpermeable dressing to allow participation. Open wounds and infectious skin conditions that cannot be adequately protected should be considered cause for medical disqualification from practice or competition (see Guideline 2a). The term “adequately protected” means that the wound or skin condition has been deemed as noninfectious and adequately treated as deemed appropriate by a health care provider and is able to be properly covered. The term “properly covered” means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will remain intact throughout the sport activity. A health care provider might exclude a studentathlete if the activity poses a risk to the health of the infected athlete (such as injury to the infected area), even though the infection can be properly covered. If wounds can be properly covered, good hygiene measures such

as performing hand hygiene before and after changing bandages and throwing used bandages in the trash should be stressed to the athlete.

Antibiotic Resistant Staph Infections There is much concern about the presence and spread of antibioticresistant Staphylococcus aureus in intercollegiate athletics across sports. Athletes are at-risk due to presence of open wounds, poor hygiene practices, close physical contact, and the sharing of towels and equipment. Institutions and conferences should continue efforts and support for the education of staff and student-athletes on the importance of proper hygiene and wound care to prevent skin infections from developing and infectious diseases from being transmitted. Staphylococcus aureus, often referred to as “staph,” are bacteria commonly carried on the skin or in the nose of healthy people. Occasionally, staph can cause an infection. Staph bacteria are one of most common causes of skin infections in the U.S. Most infections are minor, typically presenting as skin and soft tissue infections (SSTI) such as pimples, pustules and boils. They may be red, swollen, warm, painful or purulent. Sometimes, athletes confuse these lesions with insect bites in the early stages of infection. A purulent lesion could present as draining pus; yellow or white center; central point or “head”; or a palpable fluid-filled cavity.

Skin Infections in Athletics In the past, most serious staph bacterial infections were treated with antibiotics related to penicillin. In recent years, antibiotic treatment of these infections has changed because staph bacteria have become resistant to various antibiotics, including the commonly used penicillin-related antibiotics. These resistant bacteria are called methicillin-resistant Staphylococcus aureus, or MRSA. Fortunately, the first-line treatment for most purulent staph, including MRSA, skin and soft tissue infections is incision and drainage with or without antibiotics. However, if antibiotics are prescribed, patients should complete

the full course and consult physicians if the infection does not get better. The Centers for Disease Control and Prevention (CDC), American Medical Association (AMA), and Infectious Diseases Society of America (IDSA) have developed a treatment algorithm that should be reviewed; it is accessible at www.cdc.gov/ncidod/dhqp/ar_ mrsa_ca_skin.html. Staph bacteria including MRSA can spread among people having close contact with infected people. MRSA is almost always spread by direct physical contact, and not through the air. Spread may also occur through

indirect contact by touching objects contaminated by the infected skin of a person with MRSA or staph bacteria (e.g. towels, sheets, wound dressings, clothes, workout areas, sports equipment). If a lesion cannot be properly covered for the rigors of the sport, consider excluding players with potentially infectious skin lesions from practice and competition until lesions are healed. Staph bacteria including MRSA can be found on the skin and in the nose of some people without causing illness. The role of decolonization is still under investigation. Regimens

Some common recommendations include: A. Keep hands clean by washing thoroughly with soap and warm water or using an alcohol-based sanitizer routinely B. Encourage good hygiene • immediate showering after activity • ensure availability of adequate soap and water • pump soap dispensers are preferred over bar soap C. Avoid whirlpools or common tubs • individuals with active infections, open wounds, scrapes or scratches could infect others or become infected in this environment D. Avoid sharing towels, razors, and daily athletic gear • avoid contact with other people’s wounds or material contaminated from wounds E. Maintain clean facilities and equipment • wash athletic gear and towels after each use • establish routine cleaning schedules for shared equipment F. Inform or refer to appropriate health care personnel for all active skin lesions and lesions that do not respond to initial therapy • train student-athletes and coaches to recognize potentially infected wounds and seek first aid • encourage coaches and sports medicine staff to assess regularly for skin lesions • encourage health care personnel to seek bacterial cultures to establish a diagnosis G. Care and cover skin lesions appropriately before participation • keep properly covered with a proper dressing until healed • “properly covered" means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will remain intact throughout the sport activity • if wounds can be properly covered, good hygiene measures should be stressed to the studentathlete such as performing hand hygiene before and after changing bandages and throwing used bandages in the trash • if wound cannot be properly covered, consider excluding players with potentially infectious skin lesions from practice and/or competition until lesions are healed or can be covered adequately

Skin Infections in Athletics intended to eliminate MRSA colonization should not be used in patients with active infections. Decolonization regimens may have a role in preventing recurrent infections, but more data are needed to establish their efficacy and to identify optimal regimens for use in community settings. After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of decolonization when there are recurrent infections in an individual patient or members of a defined group.

precautions if suspicious skin infections appear, and immediately contact their health care provider. Individual cases of MRSA usually are not required to be reported to most local/state health departments; however, most states have laws that require reporting of certain communicable diseases, including outbreaks regardless of pathogens. So in most states if an outbreak of skin infections is detected, the local and/or state health department should be contacted.

Recognition of MRSA is critical to clinical management. Education is the key, involving all individuals associated with athletics, from student-athletes to coaches to medical personnel to custodial staff. Education should encompass proper hygiene, prevention techniques and appropriate precautions if suspicious wounds appear. Each institution should develop prevention strategies and infection control policies and procedures.

MRSA infections in the community are typically SSTI, but can also cause severe illness such as pneumonia. Most transmissions appear to be from people with active MRSA skin infections. Staph and MRSA infections are not routinely reported to public health authorities, so a precise number is not known. It is estimated that as many as 300,000 hospitalizations are related to MRSA infections each year. Only a small proportion of these have disease onset occurring in the community. It has also been estimated that there are more than 12 million outpatient (i.e., physician offices, emergency and outpatient departments) visits for suspected staph and MRSA SSTIs in the U.S. each year. Approximately 25 to 30 percent (80 million persons) of the population is colonized in the nose with staph bacteria at a given time and approximately 1.5 percent (4.1 million persons) is colonized with MRSA. In an effort to educate the public about the potential risks of MRSA, organizations such as the CDC, NCAA and the National Athletic Trainersâ&#x20AC;&#x2122; Association (NATA) have issued official statements recommending all health care personnel and physically active adults and children take appropriate

Skin Infections in Athletics

Skin Infections in Wrestling Data from the NCAA Injury Surveillance Program indicate that skin infections are associated with at least 17 percent of the practice timeloss injuries in wrestling. It is recommended that qualified personnel, including a knowledgeable, experienced physician, examine the skin of all wrestlers before any participation (practice and competition). Male student-athletes shall wear shorts and female student-athletes should wear shorts and a sports bra during medical examinations. Open wounds and infectious skin conditions that cannot be adequately protected should be considered cause for medical disqualification from practice or competition (see Guideline 2a). The term “adequately protected” means that the wound or skin condition has been deemed as non-infectious and adequately treated as deemed appropriate by a health care provider and is able to be properly covered. The term “properly covered” means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will

remain intact throughout the sport activity. A health care provider might exclude a student-athlete if the activity poses a risk to the health of the infected athlete (such as injury to the infected area), even though the infection can be properly covered. If wounds can be properly covered, good hygiene measures such as performing hand hygiene before and after changing bandages and throwing used bandages in the trash should be stressed to the athlete. (See Wrestling Rule WA-15.)

Medical Examinations Medical examinations must be conducted by knowledgeable physicians and/or certified athletic trainers. The presence of an experienced dermatologist is recommended. The examination should be conducted in a systematic fashion so that more than one examiner can evaluate problem cases. Provisions should be made for appropriate lighting and the necessary facilities to confirm and diagnose skin infections. Wrestlers who are undergoing treatment for a communicable skin disease at the time of the meet or tournament shall provide written documentation to that effect from a physician. The

status of these individuals should be decided before the screening of the entire group. The decision made by a physician and/or certified athletic trainer “on site” should be considered FINAL.

Guidelines for Disposition of Skin Infections Unless a new diagnosis occurs at the time of the medical examination conducted at the meet or tournament, the wrestler presenting with a skin lesion shall provide a completed Skin

Skin Infections in Athletics Evaluation and Participation Status Form from the team physician documenting clinical diagnosis, lab and/or culture results, if relevant, and an outline of treatment to date (i.e., surgical intervention, duration, frequency, dosages of medication). BACTERIAL INFECTIONS

(Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis or Erysipelas, Staphylococcal disease, MRSA) 1. Wrestler must have been without any new skin lesion for 48 hours before the meet or tournament. 2. Wrestler must have no moist, exudative or purulent lesions at meet or tournament time. 3. Gram stain of exudate from questionable lesions (if available). 4. Active purulent lesions shall not be covered to allow participation. See above criteria when making decisions for participation status. HIDRADENITIS SUPPURATIVA

1. Wrestler will be disqualified if extensive or purulent draining lesions are present. 2. Extensive or purulent draining lesions shall not be covered to allow participation. PEDICULOSIS

Wrestler must be treated with appropriate pediculicide and re-examined for completeness of response before wrestling. SCABIES

Wrestler must have negative scabies prep at meet or tournament time. HERPES SIMPLEX Primary Infection

1. Wrestler must be free of systemic symptoms of viral infection (fever, malaise, etc.). 2. Wrestler must have developed no

new blisters for 72 hours before the examination. 3. Wrestler must have no moist lesions; all lesions must be dried and surmounted by a FIRM ADHERENT CRUST. 4. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the meet or tournament. 5. Active herpetic infections shall not be covered to allow participation. See above criteria when making decisions for participation status. Recurrent Infection

1. Blisters must be completely dry and covered by a FIRM ADHERENT CRUST at time of competition, or wrestler shall not participate. 2. Wrestler must have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the meet or tournament. 3. Active herpetic infections shall not be covered to allow participation. See above criteria when making decisions for participation status. Questionable Cases

1. Tzanck prep and/or HSV antigen assay (if available). 2. Wrestler’s status deferred until Tzanck prep and/or HSV assay results complete. Wrestlers with a history of recurrent herpes labialis or herpes gladiatorum could be considered for season-long prophylaxis. This decision should be made after consultation with the team physician.

or tournament time and have no evidence of secondary bacterial infection. MOLLUSCUM CONTAGIOSUM

1. Lesions must be curetted or removed before the meet or tournament. 2. Solitary or localized, clustered lesions can be covered with a gaspermeable membrane, followed by tape. VERRUCAE

1. Wrestlers with multiple digitate verrucae of their face will be disqualified if the infected areas cannot be covered with a mask. Solitary or scattered lesions can be curetted away before the meet or tournament. 2. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions “adequately covered.” TINEA INFECTIONS (ringworm)

1. A minimum of 72 hours of topical therapy is required for skin lesions. 2. A minimum of two weeks of systemic antifungal therapy is required for scalp lesions. 3. Wrestlers with extensive and active lesions will be disqualified. Activity of treated lesions can be judged either by use of KOH preparation or a review of therapeutic regimen. Wrestlers with solitary, or closely clustered, localized lesions will be disqualified if lesions are in a body location that cannot be “properly covered.” 4. The disposition of tinea cases will be decided on an individual basis as determined by the examining physician and/or certified athletic trainer.

HERPES ZOSTER (chicken pox)

Skin lesions must be surmounted by a FIRM ADHERENT CRUST at meet

Skin Infections in Athletics References

1. Descriptive Epidemiology of Collegiate Men’s Wrestling Injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 Through 2003–2004. Journal of Athletic Training 2007;42(2):303–310. 2. Adams, BB.: Transmission of cutaneous infection in athletics. British Journal of Sports Medicine 34(6):413-4, 2000 Dec. 3. Anderson BJ.: The Effectiveness of Valacyclovir in Preventing Reactivation of Herpes Gladiatorum in Wrestlers. Clin J Sports Med 9(2):86-90, 1999 Apr. 4. Association for Professionals in Infection Control and Epidemiology (APIC). 1996. APIC infection control and applied epidemiology principles and practice. St. Louis: Mosby. 5. Beck, CK.: Infectious diseases in sports: Medicine and Science in Sports and Exercise 32(7 Suppl):S431-8, 2000 Jul. 6. Belongia EA, Goodman JL, Holland EJ, et. al.: An outbreak of herpes gladiatorium at a high school wrestling camp. The New England Journal of Medicine. 325(13):906-910, 1991. Cordoro, KM and Ganz, JE. Training room management of medical condition: Sports Dermatology. Clinics in Sports Medicine. 24: 565-598, 2005.

7. Cozad, A. and Jones, R. D. Disinfection and the prevention of disease. American Journal of Infection Control, 31(4): 243254, 2003. 8. Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion. (2002). Campaign to prevent antimicrobial resistant in health care settings. Available at www.cdc.gov/ drugresistance/healthcare/. 9. Dorman, JM.: Contagious diseases in competitive sport: what are the risks? Journal of American College Health 49(3):105-9, 2000 Nov. 10. Mast, E. and Goodman, R.: Prevention of Infectious Disease Transmission in Sports. SportsMedicine 24(1):1-7,1997. 11. Kohl TD, Martin DC, Nemeth R, Hill T, Evans D.: Fluconazole for the prevention and treatment of tinea gladiatorum. Pediatric Infectious Disease Journal 19(8):717-22, 2000 Aug. 12. Lindenmayer JM, Schoenfeld S, O’Grady R, Carney JK.: Methicillinresistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Archives of Internal Medicine 158(8):895-9, 1998 Apr.

13. Vasily DB, Foley JJ.: More on Tinea Corporis Gladiatorum. J Am Acad Dermatol 2002, Mar. 14. Vasily DB, Foley JJ, First Episode Herpes Gladiatorum: Treatment with Valacyclovir (manuscript submitted for publication). Weiner, R. MethicillinResistant Staphylcoccus aureus on Campus: A new challenge to college health. Journal of American College Health. 56(4):347-350. 15. Zinder SM, Basler RS, Foley J, Scarlata C, Vasily DB. National Athletic Trainers’ Association Position Statement; Skin Diseases. Journal of Athletic Training. 2010; 95 (H);411-428.

Skin Infections in Athletics National Collegiate Athletic Association SKIN EVALUATION AND PARTICIPATION STATUS (Physician Release for Student-Athlete to Participate with Skin Lesion)

Student-Athlete: ______________________________________________

Date of Exam: ____ / ____ / ____

Institution: __________________________________________________

Please Mark Location of Lesion(s):

Dual(s)/Tournament: __________________________________________ Number of Lesion(s): __________________________________________ Cultured:

Yes _______________________________________

Diagnosis: ___________________________________________________ ___________________________________________________________ Medication(s) used to treat lesion(s): ________________________________ ___________________________________________________________ Date Treatment Started: ____ / ____ / ____

Time: ________________

Earliest Date student-athlete may return to participation: ____ / ____ / ____ Physician Name (Printed): ________________________________________ Physician Signature:_____________________________________________ Specialty: _______________________________________ (M.D. or D.O.)

Office Address: _______________________________________________ Contact #: ______________________________________ Institution Certified Athletic Trainer Notified:

Yes Signature: _____________________________________________________

Note NotetotoPhysicians: Physician: Non-contagious lesions do not require treatment prior to return to participation (e.g. eczema, psoriasis, etc.). Please familiarize yourself with

NCAA Wrestling Rules which state: (refer to the NCAA Wrestling Rules and Interpretations publication for complete information) “9.6.4 … The presence of a communicable skin disease … shall be full and sufficient reason for disqualification.”

“9.6.5 … If a student-athlete has been diagnosed as having such a condition, and is currently being treated by a physician (ideally a dermatologist) who has determined that it is safe for that individual to compete without jeopardizing the health of the opponent, the student-athlete may compete. However, the studentathlete or his/her coach or athletic trainer shall provide current written documentation from the treating physician to the medical professional at the medical examination, … ” “9.6.6 … Final determination of the participant’s ability to compete shall be made by the host site’s physician or certified athletic trainer who conducts the medical examination after review of any such documentation and the completion of the exam.”

Below are some treatment guidelines that suggest MINIMUM TREATMENT before return to wrestling: (please refer to the NCAA Sports Medicine Handbook for complete information) Bacterial Infections (Furuncles, Carbuncles, Folliculitis, Impetigo, Cellulitis or Erysipelas, Staphylococcal disease, CA-MRSA): Wrestler must have been without any new skin lesion for 48 hours before the meet or tournament; completed 72 hours of antibiotic therapy and have no moist, exudative or draining lesions at meet or tournament time. Gram stain of exudate from questionable lesions (if available). Active bacterial infections shall not be covered to allow participation. Herpetic Lesions (Simplex, fever blisters/cold sores, Zoster, Gladiatorum): Skin lesions must be surmounted by a FIRM ADHERENT CRUST at competition time, and have no evidence of secondary bacterial infection. For primary (first episode of Herpes Gladiatorum) infection, the wrestler must have developed no new blisters for 72 hours before the examination; be free of signs and symptoms like fever, malaise, and swollen lymph nodes; and have been on appropriate dosage of systemic antiviral therapy for at least 120 hours before and at the time of the competition. Recurrent outbreaks require a minimum of 120 hours of oral anti-viral treatment, again so long as no new lesions have developed and all lesions are scabbed over. Active herpetic infections shall not be covered to allow participation. Tinea Lesions (ringworm): Oral or topical treatment for 72 hours on skin and 14 days on scalp. Wrestlers with solitary, or closely clustered, localized lesions will be disqualified if lesions are in a body location that cannot be adequately covered. Molluscum Contagiosum: Lesions must be curetted or removed before the meet or tournament and covered. Verrucae: Wrestlers with multiple digitate verrucae of their face will be disqualified if the infected areas cannot be covered with a mask. Solitary or scattered lesions can be curetted away before the meet or tournament. Wrestlers with multiple verrucae plana or verrucae vulgaris must have the lesions adequately covered. Hidradenitis Suppurativa: Wrestler will be disqualified if extensive or purulent draining lesions are present; covering is not permissible. Pediculosis: Wrestler must be treated with appropriate pediculicide and re-examined for completeness of response before wrestling. Scabies: Wrestler must have negative scabies prep at meet or tournament time. DISCLAIMER: The National Collegiate Athletic Association shall not be liable or responsible, in any way, for any diagnosis or other evaluation made herein, or exam performed in connection therewith, by the above named physician/provider, or for any subsequent action taken, in whole or in part, in reliance upon the accuracy or veracity of the information provided herein.

GUIDELINE 2k

Menstrual-Cycle Dysfunction January 1986 â&#x20AC;˘ Revised June 2002

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. Anne Loucks, Ohio University, in the revision of this guideline. In 80 percent of college-age women, the length of the menstrual cycle ranges from 23 to 35 days. Oligomenorrhea refers to a menstrual cycle that occurs inconsistently, irregularly and at longer intervals. Amenorrhea is the cessation of the menstrual cycle with ovulation occurring infrequently or not at all. A serious medical problem of amenorrhea is the lower level of circulating estrogen (hypoestrogenism), and its potential health consequences. The prevalence of menstrual-cycle irregularities found in surveys depends on the definition of menstrual function used, but has been reported to be as high as 44 percent in athletic women. Research suggests that failure to increase dietary energy intake in compensation for the expenditure of energy during exercise can disrupt the hypothalamic-pituitary-ovarian (HPO) axis. Exercise training appears to have no suppressive effect on the HPO axis beyond the impact of its strain on energy availability.

There are several important reasons to discuss the treatment of menstrual-cycle irregularities. One reason is infertility; fortunately, the long-term effects of menstrual cycle dysfunc-

tion appear to be reversible. Another medical consequence is skeletal demineralization, which occurs in hypoestrogenic women. Skeletal demineralization was first observed in amenorrheic athletes in 1984. Initially, the lumbar spine appeared to be the primary site where skeletal demineralization occurs, but new techniques for measuring bone mineral density show that demineralization occurs throughout the skeleton. Some women with menstrual disturbances involved in high-impact activities, such as gymnastics and figure skating, display less demineralization than women runners. Despite resumption of normal menses, the loss of bone mass during prolonged hypoestrogenemia is not completely reversible. Therefore, young women with low levels of circulating estrogen, due to menstrual irregularities, are at risk for low peak bone mass which may increase the potential for osteoporotic fractures later in life. An increased incidence of stress fractures also has been observed in the long bones and feet of women with menstrual irregularities. The treatment goal for women with menstrual irregularities is the reestablishment of an appropriate hormonal environment for the maintenance of bone health. This can be achieved by the re-establishment of a regular menstrual cycle or by hormone replacement therapy, although

neither change has been shown to result in complete recovery of the lost bone mass. Additional research is necessary to develop a specific prognosis for exercise-induced menstrual dysfunction. All student-athletes with menstrual irregularities should be seen by a physician. General guidelines include: 1. Full medical evaluation, including an endocrine work-up and bone mineral density test; 2. Nutritional counseling with specific emphasis on: a. Total caloric intake versus energy expenditure. b. Calcium intake of 1,200 to 1,500 milligrams a day; and 3. Routine monitoring of the diet, menstrual function, weight-training schedule and exercise habits. If this treatment scheme does not result in regular menstrual cycles, estrogen-progesterone supplementation should be considered. This should be coupled with appropriate counseling on hormone replacement and review of family history. Hormone-replacement therapy is thought to be important for amenorrheic women and oligomenorrheic women whose hormonal profile reveals an estrogen deficiency. The relationship between amenorrhea, osteoporosis and disordered

Menstrual-Cycle Dysfunction eating is termed the “female athlete triad.” In 1997, the American College of Sports Medicine issued a position stand calling for all individuals working with physically active girls and women to be educated about the female athlete triad and develop plans for prevention, recognition, treatment and risk reduction. Recommendations are that any student-athlete who presents with any one component of the triad be screened for the other two components and referred for medical evaluation. Other recommendations include: • All sports medicine professionals, including coaches and athletic trainers, should learn to recognize the symptoms and risks associated with the female athlete triad. • Coaches and others should avoid

pressuring female athletes to diet and lose weight and should be educated about the warning signs of eating disorders. • Sports medicine professionals, athletics administrators and officials of sport governing bodies share a responsibility to prevent, recognize and treat this disorder. • Sports medicine professionals, athletics administrators and officials of sport governing bodies should work toward offering opportunities for educating and monitoring coaches to ensure safe training practices. • Young, physically active females should be educated about proper nutrition, safe training practices, and the risks and warning signs of the female athlete triad.

References

1. American Academy of Pediatrics Committee on Sports Medicine: Amenorrhea in adolescent athletes. Pediatrics 84(2):394-395, 1989. 2. Keen AD, Drinkwater BL: Irreversible bone loss in former amenorrheic athletes. Osteoporosis International 7(4):311-315, 1997. 3. Loucks AB, Verdun M, Heath EM: Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. Journal of Applied Physiology 84(1):37-46, 1998.

4. Otis CT, Drinkwater B, Johnson M, Loucks A, Wilmore J: American College of Sports Medicine Position Stand on the Female Athlete Triad. Medicine and Science in Sports and Exercise 29(5):i-ix, 1997. 5. Shangold M, Rebar RW, Wentz AC, Schiff I: Evaluation and management of menstrual dysfunction in athletes. Journal of American Medical Association 262(12):1665-1669, 1990.

GUIDELINE 2l

Blood-Borne Pathogens and Intercollegiate Athletics April 1988 • Revised August 2004

Blood-borne pathogens are diseasecausing microorganisms that can be potentially transmitted through blood contact. The blood-borne pathogens of concern include (but are not limited to) the hepatitis B virus (HBV) and the human immunodeficiency virus (HIV). Infections with these (HBV, HIV) viruses have increased throughout the last decade among all portions of the general population. These diseases have potential for catastrophic health consequences. Knowledge and awareness of appropriate preventive strategies are essential for all members of society, including student-athletes.

traditional routes of transmission from behaviors off the athletics field. Experts have concurred that the risk of transmission on the athletics field is minimal.

The particular blood-borne patho gens HBV and HIV are transmitted through sexual contact (heterosexual and homosexual), direct contact with infected blood or blood components, and perinatally from mother to baby. In addition, behaviors such as body piercing and tattoos may place student-athletes at some increased risk for contracting HBV, HIV or Hepatitis C.

Five to 10 percent of acutely infected adults become chronically infected with the virus (HBV carriers). Currently in the United States there are approximately one million chronic carriers. Chronic complications of HBV infection include cirrhosis of the liver and liver cancer.

The emphasis for the student-athlete and the athletics health-care team should be placed predominately on education and concern about these

Hepatitis B Virus (HBV) HBV is a blood-borne pathogen that can cause infection of the liver. Many of those infected will have no symptoms or a mild flu-like illness. One-third will have severe hepatitis, which will cause the death of one percent of that group. Approximately 300,000 cases of acute HBV infection occur in the United States every year, mostly in adults.

Individuals at the greatest risk for becoming infected include those practicing risky behaviors of having unprotected sexual intercourse or sharing intravenous (IV) needles in any form. There is also evidence that

household contacts with chronic HBV carriers can lead to infection without having had sexual intercourse or sharing of IV needles. These rare instances probably occur when the virus is transmitted through unrecognized-wound or mucousmembrane exposure. The incidence of HBV in studentathletes is presumably low, but those participating in risky behavior off the athletics field have an increased likelihood of infection (just as in the case of HIV). An effective vaccine to prevent HBV is available and recommended for all college students by the American College Health Association. Numerous other groups have recognized the potential benefits of universal vaccination of the entire adolescent and young-adult population.

HIV (AIDS Virus) The Acquired Immunodeficiency Syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which infects cells of the immune system and other tissues, such as the brain. Some of those infected with HIV will remain asymptomatic for many years. Others will more rapidly develop

Blood-Borne Pathogens and Intercollegiate Athletics manifestations of HIV disease (i.e., AIDS). Some experts believe virtually all persons infected with HIV eventually will develop AIDS and that AIDS is uniformly fatal. In the United States, adolescents are at special risk for HIV infection. This age group is one of the fastest growing groups of new HIV infections. Approximately 14 percent of all new HIV infections occur in persons aged between 12 to 24 years. The risk of infection is increased by having unprotected sexual intercourse, and the sharing of IV needles in any form. Like HBV, there is evidence that suggests that HIV has been transmitted in householdcontact settings without sexual contact or IV needle sharing among those household contacts5,6. Similar to HBV, these rare instances probably occurred through unrecognizedwound or mucous-membrane exposure.

Comparison of HBV/HIV Hepatitis B is a much more “sturdy/ durable” virus than HIV and is much more concentrated in blood. HBV has a much more likely transmission with exposure to infected blood; particularly parenteral (needle-stick) exposure, but also exposure to open wounds and mucous membranes. There has been one well-documented case of transmission of HBV in the athletics setting, among sumo wrestlers in Japan. There are no validated cases of HIV transmission in the athletics setting. The risk of transmission for either HBV or HIV on the field is considered minimal; however, most experts agree that the specific epidemiologic and biologic characteristics of the HBV virus make it a realistic concern for transmission in sports with sustained, close physical contact, such as wrestling. HBV is considered to have a potentially higher risk of transmission than HIV.

Testing of StudentAthletes Routine mandatory testing of student-athletes for either HBV or HIV for participation purposes is not recommended. Individuals who desire voluntary testing based on personal reasons and risk factors, however, should be assisted in obtaining such services by appropriate campus or public-health officials. Student-athletes who engage in highrisk behavior are encouraged to seek counseling and testing. Knowledge of one’s HBV and HIV infection is helpful for a variety of reasons, including the availability of potentially effective therapy for asymptomatic patients, and modification of behavior, which can prevent transmission of the virus to others. Appropriate counseling regarding exercise and sports participation also can be accomplished.

Participation by the Student-Athlete with Hepatitis B (HBV) Infection Individual’s Health––In general, acute HBV should be viewed just as other viral infections. Decisions regarding ability to play are made according to clinical signs and symp toms, such as fatigue or fever. There is no evidence that intense, highly competitive training is a problem for the asymptomatic HBV carrier (acute or chronic) without evidence of organ impairment. Therefore, the simple presence of HBV infection does not mandate removal from play. Disease Transmission—The student-athlete with either acute or chronic HBV infection presents very limited risk of disease transmission in most sports. However, the HBV

carrier presents a more distinct transmission risk than the HIV carrier (see previous discussion of comparison of HBV to HIV) in sports with higher potential for blood exposure and sustained, close body contact. Within the NCAA, wrestling is the sport that best fits this description. The specific epidemiologic and biologic characteristics of hepatitis B virus form the basis for the following recommendation: If a student-athlete develops acute HBV illness, it is prudent to consider removal of the individual from combative, sustained close-contact sports (e.g., wrestling) until loss of infectivity is known. (The best marker for infectivity is the HBV antigen, which may persist up to 20 weeks in the acute stage). Student-athletes in such sports who develop chronic HBV infections (especially those who are e-antigen positive) should probably be removed from competition indefinitely, due to the small but realistic risk of transmitting HBV to other student-athletes.

Participation of the Student-Athlete with HIV Individual’s Health—In general, the decision to allow an HIV-positive student-athlete to participate in intercollegiate athletics should be made on the basis of the individual’s health status. If the student-athlete is asymptomatic and without evidence of deficiencies in immunologic function, then the presence of HIV infection in and of itself does not mandate removal from play. The team physician must be knowledgeable in the issues surrounding the management of HIV-infected student-athletes. HIV must be recognized as a potentially chronic disease, frequently affording the affected individual many years of

Blood-Borne Pathogens and Intercollegiate Athletics

The identity of individuals infected with a bloodborne pathogen must remain confidential. Only those persons in whom the infected studentathlete chooses to confide have a right to know about this aspect of the student-athlete’s medical history. This confidentiality must be respected in every case and at all times by all college officials, including coaches, unless the student-athlete chooses to make the fact public.

excellent health and productive life during its natural history. During this period of preserved health, the team physician may be involved in a series of complex issues surrounding the advisability of continued exercise and athletics competition. The decision to advise continued athletics competition should involve the student-athlete, the studentathlete’s personal physician and the team physician. Variables to be considered in reaching the decision include the student-athlete’s current state of health and the status of his/ her HIV infection, the nature and intensity of his/her training, and potential contribution of stress from athletics competition to deterioration of his/her health status. There is no evidence that exercise and training of moderate intensity is harmful to the health of HIVinfected individuals. What little data that exists on the effects of intense training on the HIV-infected individual demonstrates no evidence of health risk. However, there is no data looking at the effects of longterm intense training and competition at an elite, highly competitive level on the health of the HIV-infected student-athlete. Disease Transmission—Concerns of transmission in athletics revolve around exposure to contaminated blood through open wounds or mucous membranes. Precise risk of such transmission is impossible to calculate, but epidemiologic and biologic evidence suggests that it is extremely low (see section on comparison of HBV/HIV). There have been no validated reports of transmission of HIV in the athletics setting3,13. Therefore, there is no recommended restriction of studentathletes merely because they are

infected with HIV, although one court has upheld the exclusion of an HIV-positive athlete from the contact sport of karate19.

Administrative Issues The identity of individuals infected with a blood-borne pathogen must remain confidential. Only those persons in whom the infected student-athlete chooses to confide have a right to know about this aspect of the student-athlete’s medical history. This confidentiality must be respected in every case and at all times by all college officials, including coaches, unless the student-athlete chooses to make the fact public.

Athletics Health-Care Responsibilities The following recommendations are designed to further minimize risk of blood-borne pathogens and other potentially infectious organisms transmission in the context of athletics events and to provide treatment guidelines for caregivers. In the past, these guidelines were referred to as “Universal (blood and body fluid) Precautions.” Over time, the recognition of “Body Substance Isolation,” or that infectious diseases may also be transmitted from moist body substances, has led to a blending of terms now referred to as “Standard Precautions.” Standard precautions apply to blood, body fluids, secretions and excretions, except sweat, regardless of whether or not they contain visible blood. These guidelines, originally developed for health-care, have additions or modifications relevant to athletics. They are divided into two sections — the care of the studentathlete, and cleaning and disinfection of environmental surfaces.

Blood-Borne Pathogens and Intercollegiate Athletics Care of the Athlete: 1. All personnel involved in sports who care for injured or bleeding student-athletes should be properly trained in first aid and standard precautions. 2. Assemble and maintain equipment and/or supplies for treating injured/bleeding athletes. Items may include: Personal Protective Equipment (PPE) [minimal protection includes gloves, goggles, mask, fluidresistant gown if chance of splash or splatter]; antiseptics; antimicrobial wipes; bandages or dressings; medical equipment needed for treatment; appropriately labeled “sharps” container for disposal of needles, syringes and scalpels; and waste receptacles appropriate for soiled equipment, uniforms, towels and other waste. 3. Pre-event preparation includes proper care for wounds, abrasions or cuts that may serve as a source of bleeding or as a port of entry for blood-borne pathogens or other potentially infectious organisms. These wounds should be covered

with an occlusive dressing that will withstand the demands of competition. Likewise, care providers with healing wounds or dermatitis should have these areas adequately covered to prevent transmission to or from a participant. Student-athletes may be advised to wear more protective equipment on high-risk areas, such as elbows and hands. 4. The necessary equipment and/or supplies important for compliance with standard precautions should be available to caregivers. These supplies include appropriate gloves, disinfectant bleach, antiseptics, designated receptacles for soiled equipment and uniforms, bandages and/or dressings, and a container for appropriate disposal of needles, syringes or scalpels. 5. When a student-athlete is bleeding, the bleeding must be stopped and the open wound covered with a dressing sturdy enough to withstand the demands of activity before the studentathlete may continue participation in practice or competition. Current

NCAA policy mandates the immediate, aggressive treatment of open wounds or skin lesions that are deemed potential risks for transmission of disease. Participants with active bleeding should be removed from the event as soon as is practical. Return to play is determined by appropriate medical staff personnel and/or sport officials. Any participant whose uniform is saturated with blood must change their uniform before return to participation. 6. During an event, early recognition of uncontrolled bleeding is the responsibility of officials, student-athletes, coaches and medical personnel. In particular, student-athletes should be aware of their responsibility to report a bleeding wound to the proper medical personnel. 7. Personnel managing an acute blood exposure must follow the guidelines for standard precaution. Gloves and other PPE, if necessary, should be worn for direct contact with blood or other body fluids. Gloves should be changed after treating each individual participant. After removing gloves, hands should be washed. 8. If blood or body fluids are transferred from an injured or bleeding student-athlete to the intact skin of another athlete, the event must be stopped, the skin cleaned with antimicrobial wipes to remove gross contaminate, and the athlete instructed to wash with soap and water as soon as possible. NOTE: Chemical germicides intended for use on environmental surfaces should never be used on student-athletes. 9. Any needles, syringes or scalpels should be carefully disposed of in an appropriately labeled “sharps” container. Medical equipment,

Blood-Borne Pathogens and Intercollegiate Athletics bandages, dressings and other waste should be disposed of according to facility protocol. During events, uniforms or other contaminated linens should be disposed of in a designated container to prevent contamination of other items or personnel. At the end of competition, the linen should be laundered and dried according to facility protocol; hot water at temperatures of 71 degrees Celsius (160 degrees Fahrenheit) for 25minute cycles may be used.

Care of Environmental Surfaces: 1. All individuals responsible for cleaning and disinfection of blood spills or other potentially infectious materials (OPIM) should be properly trained on procedures and the use of standard precautions. 2. Assemble and maintain supplies for cleaning and disinfection of hard surfaces contaminated by blood or OPIM. Items include: Personal Protective Equipment (PPE) [gloves, goggles, mask, fluid-resistant gown if chance of splash or splatter]; supply of absorbent paper towels or disposable cloths; red plastic bag with the biohazard symbol on it or other waste receptacle according to facility protocol; and properly diluted tuberculocidal disinfectant or freshly prepared bleach solution diluted (1:100 bleach/water ratio). 3. Put on disposable gloves. 4. Remove visible organic material by covering with paper towels or disposable cloths. Place soiled towels or cloths in red bag or other waste receptacle according to facility protocol. (Use additional towels or

cloths to remove as much organic material as possible from the surface and place in the waste receptacle.) 5. Spray the surface with a properly diluted chemical germicide used according to manufacturer’s label recommendations for disinfection, and wipe clean. Place soiled towels in waste receptacle. 6. Spray the surface with either a properly diluted tuberculocidal chemical germicide or a freshly prepared bleach solution diluted 1:100, and follow manufacturer’s label directions for disinfection; wipe clean. Place towels in waste receptacle. 7. Remove gloves and wash hands. 8. Dispose of waste according to facility protocol.

Final Notes: 1. All personnel responsible for caring for bleeding individuals should be encouraged to obtain a Hepatitis B (HBV) vaccination. 2. Latex allergies should be considered. Non-latex gloves may be used for treating student-athletes and the cleaning and disinfection of environmental surfaces. 3. Occupational Safety and Health Administration (OSHA) standards for Bloodborne Pathogens (Standard #29 CFR 1910.1030) and Hazard Communication (Standard #29 CFR 1910.1200) should be reviewed for further information. Member institutions should ensure that policies exist for orientation and education of all health-care workers on the prevention and transmission of

blood-borne pathogens. Additionally, in 1992, the Occupational Safety and Health Administration (OSHA) developed a standard directed to eliminating or minimizing occupational exposure to blood-borne pathogens. Many of the recommendations included in this guideline are part of the standard. Each member institution should determine the applicability of the OSHA standard to its personnel and facilities.

Blood-Borne Pathogens and Intercollegiate Athletics References

1. AIDS education on the college campus: A theme issue. Journal of Ameri can College Health 40(2):51-100, 1991. 2. American Academy of Pediatrics: Human immunodeficiency virus (AIDS virus) in the athletic setting. Pediatrics 88(3):640-641, 1991. 3. Calabrese L, et al.: HIV infections: exercise and athletes. Sports Medicine 15(1):1-7, 1993. 4. Canadian Academy of Sports Medi cine position statement: HIV as it relates to sport. Clinical Journal of Sports Medicine 3:63-68, 1993. 5. Fitzgibbon J, et al.: Transmissions from one child to another of human immunodeficiency virus type I with azidovudine-resistance mutation. New England Journal of Medicine 329 (25):1835-1841, 1993. 6. HIV transmission between two adolescent brothers with hemophilia. Morbidity and Mortality Weekly Report 42(49):948-951, 1993. 7. Kashiwagi S, et al.: Outbreak of hepatitis B in members of a high-school sumo wrestling club. Journal of American Medical Association 248 (2):213-214, 1982. 8. Klein RS, Freidland GH: Transmission of human immunodeficiency virus type 1 (HIV-1) by exposure to blood: defining the risk. Annals of Internal Medicine 113(10):729-730, 1990. 9. Public health services guidelines for counseling and antibody testing to prevent HIV infection and AIDS. Morbidity and Mortality Weekly Report 36(31):509-515, 1987. 10. Recommendations for prevention of HIV transmission in health care settings. Morbidity and Mortality Weekly Report 36(25):3S-18S, 1987.

11. United States Olympic Committee Sports Medicine and Science Committee: Transmission of infectious agents during athletic competition, 1991. (1750 East Boulder Street, Colorado Springs, CO 80909) 12. Update: Universal precautions for prevention of transmission by human immunodeficiency virus, hepatitis B virus, and other blood borne pathogens in health care settings. Morbidity and Mortality Weekly Report 37:377-388, 1988. 13. When sports and HIV share the bill, smart money goes on common sense. Journal of American Medical Association 267(10):1311-1314, 1992. 14. World Health Organization consensus statement: Consultation on AIDS and sports. Journal of American Medical Association 267(10):1312, 1992. 15. Human immunodeficiency virus (HIV) and other blood-borne pathogens in sports. Joint position statement by the American Medical Society for Sports Medicine (AMSSM) and the American Academy of Sports Medicine (AASM). The American Journal of Sports Medicine 23(4):510-514, 1995. 16. Most E, et al.: Transmissions of blood-borne pathogens during sport: risk and prevention. Annals of Internal Medicine 122(4):283-285, 1995. 17. Brown LS, et al.: Bleeding injuries in professional football: estimating the risk for HIV transmission. Annals of Internal Medicine 122(4):271-274, 1995. 18. Arnold BL: A review of selected blood-borne pathogen statements and federal regulations. Journal of Athletic Training 30(2):171-176, 1995. 19. Montalov v. Radcliffe, 167 F. 3d 873 (4th Cir. 1999), cert. denied, 120 S Ct. 48 1999.

GUIDELINE 2m

The Use of Local Anesthetics in College Athletics June 1992 • Revised June 2004

The use of local injectable anesthetics to treat sports-related injuries in college athletics is primarily left to the discretion of the physician treating the individual, since there is little scientific research on the subject. This guideline provides basic recommendations for the use of these substances, which commonly include lidocaine (Xylo caine), one or two percent; bupivacaine (Marcaine), 0.25 to 0.50 percent; and mepivacaine (Carbo caine), three percent. The following recommendations do not include the use of corticosteroids. It is recommended that: 1. These agents should be administered only by a qualified clinician who is licensed to perform this procedure and who is familiar with these agents’ actions, reactions, interactions and complications. The treating clinician should be well aware of the quantity of these agents that can be safely injected. 2. These agents should only be administered in facilities equipped to handle any allergic reaction, including a cardiopulmonary emergency, which may follow their use.

3. These agents should only be administered when medically justified, when the risk of administration is fully explained to the patient, when the use is not harmful to continued athletics activity and when there is no enhancement of a risk of injury. The following procedures are not recommended: 1. The use of local anesthetic injections if they jeopardize the ability of the student-athlete to protect himself or herself from injury. 2. The administration of these drugs by anyone other than a qualified clinician licensed to perform this procedure. 3. The use of these drugs in combination with epinephrine or other vasoconstrictor agents in fingers, toes, earlobes and other areas where a decrease in circulation, even if only temporary, could result in significant harm.

GUIDELINE 2n

The Use of Injectable Corticosteroids in Sports Injuries June 1992 â&#x20AC;˘ Revised June 2004

Corticosteroids, alone or in combination with local anesthetics, have been used for many years to treat certain sports-related injuries. This guideline is an attempt to identify specific circumstances in which corticosteroids may be appropriate and also to remind both physicians and student-athletes of the inherent dangers associated with their use. The most common reason for the

use of corticosteroids in athletics is the treatment of chronic overuse syndromes such as bursitis, tenosynovitis and muscle origin pain (for example, lateral epicondylitis). They have also been used to try to prevent redevelopment of a ganglion, and to reduce keloid scar formation. Rarely is it appropriate to treat acute syndromes such as acromio-clavicular (AC) joint separations or hip pointers with a

corticosteroid. There is still much to be learned about the effects of intra-articular, intraligamentous or intratendinous injection of corticosteroids. ReÂsearchers have noted reduced synthesis of articular cartilage after corticosteroid administration in both animals and human models. However, a causal relationship between the intra-articular corticosteroid and degeneration of

The Use of Injectable Corticosteroids in Sports Injuries articular cartilage has not been established. Research also has shown that a single intraligamentous or multiple intra-articular injections have the potential to cause significant and long-lasting deterioration in the mechanical properties of ligaments and collagenous tissues in animal models. Finally, studies have shown significant degenerative changes in active animal tendons treated with a corticosteroid as early as 48 hours after injection. This research provides the basis for the following recommendations regarding the administration of corticosteroids in college athletics. It is recommended that: 1. Injectable corticosteroids should be administered only after more conservative treatments, including nonsteroidal anti-inflammatory agents, rest, ice, ultrasound and various treatment modalities, have been exhausted. 2. Only those physicians who are knowledgeable about the chemical makeup, dosage, onset of action, duration and potential toxicity of these agents should administer corticosteroids. 3. These agents should be administered only in facilities that are equipped to deal with allergic reactions, including cardiopulmonary emergencies. 4. Repeated corticosteroid injections at a specific site should be done only after the consequences and benefits of the injections have been thoroughly evaluated. 5. Corticosteroid injections only should be done if a therapeutic effect is medically warranted and the student-athlete is not subject to either short- or long-term significant risk.

6. These agents should only be

administered when medically justified, when the risk of administration is fully explained to the patient, when the use is not harmful to continued athletics activity and when there is no enhancement of a risk of injury. The following procedures are not recommended: 1. Intra-articular injections, particularly in major weight-bearing joints. Intra-articular injections have a potential softening effect on articular cartilage. 2. Intratendinous injections, since such injections have been associated with an increased risk of rupture. 3. Administration of injected corticosteroids immediately before a competition. 4. Administration of corticosteroids in acute trauma. 5. Administration of corticosteroids in infection.

References

1. Corticosteroid injections: balancing the benefits. The Physician and Sports Medicine 22(4):76, 1994. 2. Corticosteroid Injections: Their Use and Abuse. Journal of the American Academy of Orthopaedic Surgeons 2:133-140, 1994. 3. Kennedy JC, Willis RD: The effects of local steroid injections on tendons: A biomechanical and microscopic correlative study. American Journal of Sports Medicine 4:11-21, 1970. 4. Leadbetter WB: Corticosteroid injection therapy in sports injuries. In: Sports Induced Inflammation Park Ridge, IL: American Academy of Orthopedic Surgeons, pp. 527-545, 1990. 5. Mankin HJ, Conger KA: The acute effects of intra-articular hydrocortisone on articular cartilage in rabbits. Journal of Bone and Joint Surgery 48A:13831388, 1966. 6. Noyes FR, Keller CS, Grood ES, et al.: Advances in the understanding of knee ligament injuries, repair and reha bilitation. Medicine and Science in Sports and Exercise 16:427-443, 1984. 7. Noyes FR, Nussbaum NS, Torvik PT, et al.: Biomechanical and ultrastructural changes in ligaments and tendons after local corticosteroid injections. Abstract, Journal of Bone and Joint Surgery 57A:876, 1975. 8. Pfenninger JL: Injections of joints and soft tissues: Part I. General guidelines. American Family Physician 44(4):11961202, 1991. 9. Pfenninger JL: Injections of joints and soft tissues: Part II. Guidelines for specific joints. American Family Physician 44(5):1690-1701, 1991.

GUIDELINE 2o

Depression: Interventions for Intercollegiate Athletics June 2006

The NCAA Committee on Com petitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Sam Maniar, Licensed Psychologist, The Ohio State University; Margot Putukian, Team Physician, Princeton University; and the National Institute of Mental Health, Bethesda, Maryland; for their original content. Depression is more than the blues, let-downs from a game loss, or the normal daily ups and downs. It’s feeling “down” and “low” and “hopeless” for weeks at a time. Depression is a serious medical condition. Little research has been conducted on depression among studentathletes; however, preliminary data indicate that student-athletes experience depressive symptoms and illness at similar or increased rates than non-athlete students. Approximately 9.5 percent of the population — or one out of 10 people — suffer from a depressive illness during any given one-year period. Women are twice as likely to experience depression as men; however, men are less likely to admit to depression. Moreover, even

though the majority of peoples’ depressive disorders can be improved, most people with depression do not seek help.

physical demands of their sport, and the time commitment of participation, strength and conditioning, and skill instruction.

Depression is important to assess among student-athletes because it impacts overall personal well-being, athletic performance, academic performance and injury healing. No two people become depressed in exactly the same way, but with the proper treatment 80 percent of those who seek help get better, and many people begin to feel better in just a few weeks.

Most athletes participate almost year-round, often missing holidays, school and summer breaks, classes and even graduation. In addition, if they struggle in their performance, have difficulty interacting with the coach or teammates, or they lose their passion for their sport, it can be very difficult to handle. Many athletes also define themselves by their role as an athlete, and an injury can be devastating.

Depression and Intercollegiate Athletics Student-athletes may experience depression because of genetic predisposition, developmental challenges of college transitions, academic stress, financial pressures, interpersonal difficulties and grief over loss/failure. Participation in athletics does not provide student-athletes any immunity to these stresses, and it has the potential to pose additional demands. Student-athletes must balance all of the demands of being a college student along with athletics demands. This includes the

Some attributes of athletics and competition can make it extremely difficult for student-athletes to obtain help. They are taught to “play through the pain,” struggle through adversity, handle problems on their own and “never let your enemies see you cry.” Seeking help is seen as a sign of weakness, when it should be recognized as a sign of strength. Team dynamics also may be a factor. Problems often are kept “in the family,” and it is common for teams to try to solve problems by themselves, often ignoring signs or symptoms of more serious issues.

Depression: Intervention for Intercollegiate Athletics Depression affects approximately 19 million Americans, and for many, the symptoms first appear before or during college. Early identification and intervention (referral/treatment) for depression or other mental illness is extremely important, yet may be inhibited within the athletics culture for the following reasons: • Physical illness or injury is more readily measured and treated within sports medicine, and often there is less comfort in addressing mental illness. • Mental wellness is not always perceived as necessary for athletic performance.

Available online at NCAA.org/ health-safety.

• The high profile of studentathletes may magnify the attention paid on campus and in the surrounding community when an athlete seeks help. • History and tradition drive athletics and can stand as barriers to change. • The athletics department may have difficulty associating mental illness with athletic participation.

Enhancing knowledge and awareness of depressive disorders

Sports medicine staff, coaches and student-athletes should be knowledgeable about the types of depression and related symptoms. Men may be more willing to report fatigue, irritability, loss of interest in work or hobbies and sleep disturbances, rather than feelings of sadness, worthlessness and excessive guilt, which are commonly associated with depression in women. Men often mask depression with the use of alcohol or drugs, or by the socially acceptable habit of working excessively long hours.

Types of Depressive Illness Depressive illnesses come in different forms. The following are general descriptions of the three most prevalent, though for an individual the number, severity and duration of symptoms will vary. Major Depression, or “clinical depression,” is manifested by a combination of symptoms that interfere with a person’s once pleasurable activities (school, sport, sleep, eating, work). Studentathletes experiencing five or more symptoms as noted in Table 1 for two weeks or longer, or noticeable changes in usual functioning, are factors that should prompt referral to the team physician or mental health professional. Fifteen percent of people with major depression die by suicide. The rate of suicide in men is four times that of women, though more women attempt it during their lives. Dysthymia is a less severe form of depression that tends to involve long-term, chronic depressive symptoms. Although these symptoms are not disabling, they do affect the individual’s overall functioning. Bipolar Disorder, or “manicdepressive illness,” involves cycling mood swings from major depressive episodes to mania. Depressive epi sodes may last as little as two weeks, while manic episodes may last as little as four days. Manic signs and symptoms are presented in Table 2. In addition to the three types of depressive disorders, studentathletes may suffer from an Adjust ment Disorder. Adjustment disorders occur when an individual experiences depressive (or anxious) symptoms in response to a specific event or stressor (e.g., poor

Depression: Intervention for Intercollegiate Athletics performance, poor relationship with a coach). An adjustment disorder can also progress into major depressive disorder.

Establishing a relationship with mental health services Athletics departments should identify and foster relationships with mental health resources on campus or within the local community that will enable the development of a diverse and effective referral plan addressing the mental well-being of their studentathletes and staff. Because studentathletes are less likely to use counseling than nonathlete students, increasing interaction among mental health staff members, coaches and student-athletes will improve compliance with referrals. Athletics departments can seek psychological services and mental health professionals from the following resources. • Athletics department sports medicine services. • Athletics department academic services. • University student health and counseling services. • University medical school. • University graduate programs (health sciences, education, medical, allied health). • Local community.

Screening for depression and related risk for suicide One way to ensure an athletics department is in tune with studentathletes’ mental well-being is to systematically include mental health check-ups, especially around highrisk times such as the loss of a coach, significant injury, being cut

from the team and catastrophic events. Members of the sports medicine team and/or licensed mental health professionals should also screen athletes for depression at pre-established points in time (e.g., pre-participation, exit interviews). Research indicates that sports medicine professionals are better equipped to assess depression with the use of appropriate mental health instruments; simply asking about depression is not recommended. A thorough assessment on the part of a mental health professional is also imperative to differentiate major depression from dysthymia and bipolar disorder, and other conditions, such as medication use, viral illness, anxiety disorders, overtraining and illicit substance use. Depressive disorders may co-exist with substance-abuse disorders, panic disorder, obsessivecompulsive disorder, anorexia nervosa, bulimia nervosa and borderline personality disorder. For depression screening, it is recommended that sports medicine teams use the Center for Epi demiological Studies Depression (CES-D) Scale published by the National Institute for Mental Health (NIMH). The CES-D is free to use and available at www.nimh.nih.gov. Other resources include such programs as QPR (Question, Persuade, Refer) Gatekeeper training; the Jed Foundation U Lifeline; and the Screening for Mental Health Depression and Anxiety Screenings. Information about these programs, and ways to incorporate them into studentathlete check-ups, can be found at NCAA.org/health-safety.

Seeking help Most individuals who suffer from depression will fully recover to lead productive lives. A combination of

counseling and medication appears to be the most effective treatment for moderately and severely depressed individuals. Although some improvement in mood may occur in the first few weeks, it typically takes three to four weeks of treatment to obtain the full therapeutic effect. Medication should only be taken and/or stopped under the direct care of a physician, and the team physicians should consult with psychiatrists regarding complex mental health issues. A referral should be made to a licensed mental health professional when coaches or sports medicine staff members witness any of the following with their studentathletes: • Suicidal thoughts. • Multiple depressive symptoms. • A few depressive symptoms that persist for several weeks. • Depressive symptoms that lead to more severe symptoms or destructive behaviors. • Alcohol and drug abuse as an attempt at self treatment. • Overtraining or burnout, since depression has many of the same symptoms. Coaches and sports medicine staff members should follow the following guidelines in order to help enhancing student-athlete compliance with mental health referrals: • Express confidence in the mental health professional (e.g., “I know that other student-athletes have felt better after talking to Dr. Kelly.”). • Be concrete about what counseling is and how it could help (e.g., “Amy can help you focus more on your strengths.”).

Depression: Intervention for Intercollegiate Athletics • Focus on similarities between the student-athlete and the mental health professional (e.g., “Bob has a sense of humor that you would appreciate.” “Dr. Jones is a former college student-athlete and understands the pressures student-athletes face.”). • Offer to accompany the studentathletes to their initial appointment. • Offer to make the appointment (or have the student-athlete make the appointment) while in your office. • Emphasize the confidentiality of medical care and the referral process. The following self-help strategies may improve mild depression symptoms:

Individuals might present: • Decreased performance in school or sport. • Noticeable restlessness. • Significant weight loss or weight gain. • Decrease or increase in appetite nearly every day (fluctuating?). Individuals might express: • Indecisiveness. • Feeling sad or unusually crying. • Difficulty concentrating. • Lack of or loss of interest or pleasure in activities that were once enjoyable (hanging out with friends, practice, school, sex). • Depressed, sad or “empty” mood for most of the day and nearly every day. • Recurrent thoughts of death or thoughts about suicide. • Frequent feelings of worthlessness, low self-esteem, hopelessness, helplessness or inappropriate guilt.

• Reduce or eliminate the use of alcohol and drugs.

Table 2

• Break large tasks into smaller ones; set realistic goals.

MANIC SIGNS AND SYMPTOMS

• Engage in regular, mild exercise. • Eat regular and nutritious meals. • Participate in activities that typically make you feel better. • Let family, friends and coaches help you. • Increase positive or optimistic thinking. • Engage in regular and adequate sleep habits.

Table 1

DEPRESSIVE SIGNS AND SYMPTOMS

Individuals might present: • Abnormal or excessive elation. • Unusual irritability. • Markedly increased energy. • Poor judgment. • Inappropriate social behavior. • Increased talking. Individuals might express: • Racing thoughts. • Increased sexual desire. • Decreased need for sleep. • Grandiose notions.

Depression: Intervention for Intercollegiate Athletics

Using a simple tool such as this can help students and staff look for signs of depression. Put a check mark by each sign that describes you:  I am really sad most of the time.  I don’t enjoy doing the things I’ve always enjoyed doing.  I don’t sleep well at night and am very restless.  I am always tired. I find it hard to get out of bed.  I don’t feel like eating much.  I feel like eating all the time.  I have lots of aches and pains that don’t go away.  I have little to no sexual energy.  I find it hard to focus and am very forgetful.  I am mad at everybody and everything.  I feel upset and fearful, but can’t figure out why.  I don’t feel like talking to people.  I feel like there isn’t much point to living, nothing good is going to happen to me.  I don’t like myself very much. I feel bad most of the time.  I think about death a lot. I even think about how I might kill myself. If you checked several boxes, call your doctor. Take the list to show the doctor. You may need to get a check-up and find out if you have depression.

References

1. Backmand J, et. al. Influence of physical activity on depression and anxiety of former elite athletes. International Journal of Sports Medicine. 2003. 24(8):609-919. 2. Hosick, M. Psychology of sport more than performance enhancement. The NCAA News. March 14, 2005. Available online. 3. National Institute of Mental Health. Depression. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services; 2000. (NIH Publication No 02-3561). 25 pages.

Available from www.nimh.nih.gov/publicat/ nimhdepression.pdf. 4. Maniar SD, Chamberlain R, Moore N. Suicide risk is real for student-athletes. The NCAA News. November 7, 2005. Available online. 5. Maniar SD, Curry LA, SommersFlanagan J, Walsh JA. Student-athlete preferences in seeking help when confronted with sport performance problems. The Sport Psychologist. 2001;15(2):205-23. 6. Pinkerton RS, Hinz LD, Barrow JC. The

college student-athlete: Psychological considerations and interventions. Journal of American College Health. 1989;37(5):218-26. 7. Putukian, M, Wilfert, M. Studentathletes also face dangers from depression. The NCAA News. April 12, 2004. Available online. 8. Schwenk, TL. The stigmatization and denial of mental illness in athletes. British Journal of Sports Medicine. 2000. 34:4-5.

Special populations Also found on the NCAA website at: NCAA.org/health-safety

GUIDELINE 3a

Participation by the Student-Athlete with Impairment January 1976 • Revised August 2004

In accordance with the recommendations of major medical organizations and pursuant to the requirements of federal law (in particular, the Rehabilitation Act of 1976 and The Americans With Disabilities Act), the NCAA encourages participation by student-athletes with physical or mental impairments in intercollegiate athletics and physical activities to the full extent of their interests and abilities. It is imperative that the university’s sports medicine personnel assess a student-athlete’s medical needs and specific limitations on an individualized basis so that needless restrictions will be avoided and medical precautions will be taken to minimize any enhanced risk of harm to the student-athlete or others from participation in the subject sport.

A student-athlete with impairment should be given an opportunity to participate in an intercollegiate sport if he or she has the requisite abilities and skills in spite of his or her impairment, with or without a reasonable accommodation. Medical exclusion of a studentathlete from an athletics program should occur only when a mental or physical impairment presents a

significant risk of substantial harm to the health or safety of the student-athlete and/or other participants that cannot be eliminated or reduced by reasonable accommodations. Recent judicial decisions have upheld a university’s legal right to exclude a student-athlete from competition if the team physician has a reasonable medical basis for determining that athletic competition creates a significant risk of harm to the student-athlete or others. When student-athletes with impairments not otherwise qualified to participate in existing athletics programs are identified, every means should be explored by member institutions to provide suitable sport and recreational programs in the most appropriate, integrated settings possible to meet their interests and abilities.

his or her parent(s) or guardian. The following factors should be considered on an individualized basis in determining whether he or she should participate in a particular sport:

Participation Considerations

5. The ability of the student-athlete [and, in the case of a minor, the parent(s) or guardian] to fully understand the material risks of athletic participation.

Before allowing any student-athlete with an impairment to participate in an athletics program, it is recommended that an institution require joint approval from the physician most familiar with the student-athlete’s condition, the team physician, and an appropriate official of the institution as well as

1. Available published information regarding the medical risks of participation in the sport with the athlete’s mental or physical impairment; 2. The current health status of the student-athlete; 3. The physical demands of the sport and position(s) that the student-athlete will play; 4. Availability of acceptable protective equipment or measures to reduce effectively the risk of harm to the student-athlete or others; and

Organ Absence or Non-function When the absence or non-function of a paired organ constitutes the impairment, the following specific

Participation by the Student-Athlete with Impairment issues need to be addressed with the student-athlete and his/her parents or guardian (in the case of a minor). The following factors should be considered: 1. The quality and function of the remaining organ; 2. The probability of injury to the remaining organ; and 3. The availability of current protective equipment and the likely effectiveness of such equipment to prevent injury to the remaining organ.

References

1. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation. Pediatrics. 94(5): 757-60, 1994. 2. Mitten, MJ. Enhanced risk of harm to one’s self as a justification for exclusion from athletics. Marquette Sports Law Journal. 8:189-223, 1998.

Medical Release When a student-athlete with impairment is allowed to compete in the intercollegiate athletics program, it is recommended that a properly executed document of understanding and a waiver release the institution for any legal liability for injury or death arising out of the student-athlete’s participation with his or her mental or physical impairment/medical condition. The following parties should sign this document: the student-athlete, his or her parents/guardians, the team physician and any consulting physician, a representative of the institution’s athletics department, and the institution’s legal counsel. This document evidences the student-athlete’s understanding of his or her medical condition and the potential risks of athletic participation, but it may not immunize the institution from legal liability for injury to the studentathlete.

GUIDELINE 3b

Pregnancy in the Student-Athlete January 1986 • Revised June 2008

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. James Clapp, FACSM, in the revision of this guideline. Pregnancy Policies Pregnancy places unique challenges on the student-athlete. Each member institution should have a policy clearly outlined to address the rights and responsibilities of the pregnant student-athlete. The policy should address: • Where the student-athlete can receive confidential counseling; • Where the student-athlete can access timely medical and obstetrical care; • How the pregnancy may affect the student-athlete’s team standing and institutional grants-in-aid; • That pregnancy should be treated as any other temporary health condition regarding receipt of institutional grants-in-aid; and • That NCAA rules permit a oneyear extension of the five-year period of eligibility for a female student-athlete for reasons of pregnancy.

Student-athletes should not be forced to terminate a pregnancy because of financial or psychological pressure or fear of losing their institutional grants-inaid. See Bylaw 15.3.4.3, which

specifies that institutional financial aid based in any degree on athletics ability may not be reduced or canceled during the period of its award because of an injury, illness or physical or mental medical condition. The team’s certified athletic trainer or team physician is often approached in confidence by the student-athlete. The sports medicine staff should be wellversed in the athletics department’s policies and be able to access the identified resources. The sports medicine staff should respect the student-athlete’s requests for confidentiality until such time when there is medical reason to withhold the student-athlete from competition.

Exercise in Pregnancy Assessing the risk of intense, strenuous physical activity in pregnancy is difficult. There is some evidence that women who exercise during pregnancy have improved cardiovascular function, limited weight gain and fat retention, improved attitude and mental state, easier and less complicated labor, and enhanced postpartum recovery. There is no evidence that increased activity increases the risk of

spontaneous abortion in uncomplicated pregnancies. There are, however, theoretical risks to the fetus associated with increased core body temperatures that may occur with exercise, especially in the heat. The fetus may benefit from exercise during pregnancy in several ways, including an increased tolerance for the physiologic stresses of late pregnancy, labor and delivery. The safety of participation in individual sports by a pregnant woman should be dictated by the movements and physical demands required to compete in that sport and the previous activity level of the individual. The American College of Sports Medicine discourages heavy weight lifting or similar activities that require straining or valsalva. Exercise in the supine position after the first trimester may cause venous obstruction and conditioning or training exercises in this position should be avoided. Sports with increased incidences of bodily contact (basketball, ice hockey, field hockey, lacrosse, soccer, rugby) or falling (gymnastics, equestrian, downhill skiing) are generally considered

Participation by the Pregnant Student-Athlete higher risk after the first trimester because of the potential risk of abdominal trauma. The studentathlete’s ability to compete may also be compromised due to changes in physiologic capacity, and musculoskeletal issues unique to pregnancy. There is also concern that in the setting of intense competition a pregnant athlete will be less likely to respond to internal cues to moderate exercise and may feel pressure not to let down the team. The American College of Obstetrics and Gynecology states that competitive athletes can remain active during pregnancy but need to modify their activity as medically indicated and require close supervision. If a student-athlete chooses to compete while pregnant, she should: • Be made aware of the potential risks of her particular sport and exercise in general while pregnant; • Be encouraged to discontinue exercise when feeling over-exerted or when any warning signs (Table 1) are present; • Follow the recommendations of her obstetrical provider in coordination with the team physician; and • Take care to remain wellhydrated and to avoid over-heating. After delivery or pregnancy termination, medical clearance is recommended to ensure the student-athlete’s safe return to athletics. (See Follow-up Exam inations section of Guideline 1b.) The physiologic changes of pregnancy persist four to six weeks postpartum, however, there have been no known maternal complications from resumption of training. Care should be taken to individualize return to practice and competition.

Table 1

Warning Signs to Terminate Exercise While Pregnant Vaginal Bleeding Shortness of Breath Before Exercise Dizziness Headache Chest Pain Calf Pain or Swelling Pre-term Labor Decreased Fetal Movement Amniotic Fluid Leakage Muscle Weakness

References

1. Pregnant & Parenting Student-athletes: Resources and Model Policies. 2009. NCAA. org/health-safety. 2. American College of Obstetrics and Gynecology Committee on Obstetric Practice: Exercise During Pregnancy and the Postpartum Period. Obstetrics and Gynecology 99(1) 171-173, 2002. 3. American College of Sports Medicine: Exercise During Pregnancy. In: Current Comment from the American College of Sports Medicine, Indianapolis, IN, August 2000. 3. Clapp JF: Exercise During Pregnancy, A Clinical Update. Clinics in Sports Medicine 19(2) 273-286, 2000.

GUIDELINE 3c

The Student-Athlete with Sickle Cell Trait October 1975 • Revised June 2008

Sickle cell trait is not a disease. It is the inheritance of one gene for normal hemoglobin (A) and one gene for sickle hemoglobin (S), giving the genotype AS. Sickle cell trait (AS) is not sickle cell anemia (SS), in which two abnormal genes are inherited. Sickle cell anemia causes major anemia and many clinical problems, whereas sickle cell trait causes no anemia and few clinical problems. Sickle cell trait will not turn into the disease. However, it is possible to have symptoms of the disease under extreme conditions of physical stress or low oxygen levels. In some cases, athletes with the trait have expressed significant distress, collapsed and even died during rigorous exercise.

and consistent with a long, healthy life. As they get older, some persons with the trait become unable to concentrate urine normally, but this is not a key problem for college athletes. Most athletes complete their careers without any complications. However, there are three constant concerns that exist for athletes with sickle cell trait: gross hematuria, splenic infarction, and exertional rhabdomyolysis, which can be fatal.

People at high risk for having sickle cell trait are those whose ancestors come from Africa, South or Central America, the Caribbean, Mediterranean countries, India, and Saudi Arabia. Sickle cell trait occurs in about 8 percent of the U.S. African-American population and rarely (between one in 2,000 to one in 10,000) in the Caucasian population. It is present in athletes at all levels, including high school, collegiate, Olympic and professional. Sickle cell trait is no barrier to outstanding athletic performance.

Splenic infarction can occur in people with sickle cell trait, typically at altitude. The risk may begin at 5,000 feet and increases with rising altitude. Vigorous exercise (e.g., skiing, basketball, football, hiking, anaerobic conditioning) may increase the risk. Splenic infarction causes left upper quadrant or lower chest pain, often with nausea and vomiting. It can mimic pleurisy, pneumothorax, side stitch, or renal colic. Splenic infarction at altitude has occurred in athletes with sickle trait. Athletes should consult a physician for return-to-play clearance.

Sickle cell trait is generally benign

Gross hematuria, visible blood in the urine, usually from the left kidney, is an occasional complication of sickle cell trait. Athletes should consult a physician for return-to-play clearance.

Exertional rhabdomyolysis can be life-threatening. During intense exertion and hypoxemia, sickled red cells can accumulate in the blood. Dehydration worsens exertional sickling. Sickled red cells can “logjam” blood vessels in working muscles and provoke ischemic rhabdomyolysis. Exertional rhabdomyolysis is not exclusive to athletes with sickle cell trait. Planned emergency response and prompt access to medical care are critical components to ensure adequate response to a collapse or athlete in distress. The U.S. Armed Forces linked sickle trait to sudden unexplained death during basic training. Recruits with sickle cell trait were about 30 times more likely to die than other recruits. The deaths were initially classified as either acute cardiac arrest of undefined mechanism or deaths related to heat stroke, heat stress, or rhabdomyolysis. Further analysis showed that the major risk was severe exertional rhabdomyolysis, a risk that was about 200 times greater for recruits with sickle cell trait. Deaths among college athletes with sickle cell trait, almost exclusively in football dating back to 1974, have been from exertional rhabdomyolysis, including early cardiac death from hyperkalemia and lactic acidosis and later

The Student-Athlete with Sickle Cell Trait metabolic death from acute myoglobinuric renal failure. In other cases, athletes have survived collapses while running a distance race, sprinting on a basketball court or football field, and running timed laps on a track. The harder and faster athletes go, the earlier and greater the sickling. Sickling can begin in only two to three minutes of sprinting, or in any other all-out exertion of sustained effort, thus quickly increasing the risk of collapse. Athletes with sickle cell trait cannot be “conditioned” out of the trait and coaches pushing these athletes beyond their normal physiological response to stop and recover place these athletes at an increased risk for collapse. A sickling collapse is a medical emergency. Even the most fit athletes can experience a sickling collapse. Themes from the literature describe sickling athletes with ischemic pain and muscle weakness rather than muscular cramping or “locking up.” Unlike cardiac collapse (with ventricular fibrillation), the athlete who slumps to the ground from sickling can still talk. This athlete is typically experiencing major lactic acidosis, impending shock, and imminent hyperkalemia from sudden rhabdomyolysis that can lead to life-threatening complications or even sudden death. The emergent management of a sickling collapse is covered in the references. Screening for sickle cell trait as part of the medical examination process is an institutional decision. The references allude to growing support for the practical benefits of screening and campuses that screen are increasing in frequency. Screening can be accomplished

with a simple blood test that is relatively inexpensive. Although sickle cell trait screening is normally performed on all U.S. babies at birth, many studentathletes may not know whether they have the trait. Following the recommendations of the National Athletic Trainers Association (NATA) and the College of American Pathologists (CAP), if the trait is not known, the NCAA recommends athletics departments confirm sickle cell trait status in all student-athletes during the medical examination (Bylaw 17.1.5) period. In a 2006 survey of NCAA Division I Football Bowl Subdivision schools, 64 percent of respondents screened for sickle cell trait; however, precautions were inconsistent. If screening is done, it may be done on a voluntary basis with the informed consent of the student-athlete and should be offered to all studentathletes, because sickle cell trait occurs in all populations. If a test is positive, the student-athlete should be offered counseling on the implications of sickle cell trait, including health, athletics and family planning. Screening can be used as a gateway to targeted precautions.

NCAA Fact Sheets and Video for Coaches and Student-Athletes are available at www.NCAA.org/ health-safety.

Beginning August 1, 2010, Division I is requiring studentathletes new to their campus to complete a sickle cell solubility test, show results of a prior test, or sign a written release declining the test. See Division I Bylaw 17.1.5.1.

Precautions can enable studentathletes with sickle cell trait to thrive in their sport. These precautions are outlined in the references and in a 2007 NATA Consensus Statement on Sickle Cell Trait and the Athlete. Knowledge of a student-athlete’s sickle cell status should facilitate prompt and appropriate medical care during a medical emergency. Student-athletes with sickle cell trait should be knowledgeable of these precautions and institutions

The Student-Athlete with Sickle Cell Trait should provide an environment in which these precautions may be activated. In general, these precautions suggest student-athletes with sickle cell trait should: • Set their own pace. • Engage in a slow and gradual preseason conditioning regimen to be prepared for sports-specific performance testing and the rigors of competitive intercollegiate athletics. • Build up slowly while training (e.g., paced progressions). • Use adequate rest and recovery

between repetitions, especially during “gassers” and intense station or “mat” drills. • Not be urged to perform all-out exertion of any kind beyond two to three minutes without a breather. • Be excused from performance tests such as serial sprints or timed mile runs, especially if these are not normal sport activities. • Stop activity immediately upon struggling or experiencing symptoms such as muscle pain, abnormal weakness, undue fatigue

or breathlessness. • Stay well hydrated at all times, especially in hot and humid conditions. • Maintain proper asthma management. • Refrain from extreme exercise during acute illness, if feeling ill, or while experiencing a fever. • Access supplemental oxygen at altitude as needed. • Seek prompt medical care when experiencing unusual distress.

References

1. NATA Consensus Statement: Sickle cell trait and the athlete, June 2007. 2. Clarke CE, Paul S, Stilson M, Senf J: Sickle cell trait preparticipation screening practices of collegiate physicians. Clin J Sport Med 2007;16:440a 3. Eichner ER: Sickle cell trait. J Sport Rehab 2007;16:197-203. 4. Eichner ER: Sickle cell trait and athletes: three clinical concerns. Curr Sports Med Rep 2007;6:134-135. 5. Kark JA, Posey DM, Schumacher HR, Ruehle CJ: Sickle-cell trait as a risk factor for sudden death in physical

training. N Engl J Med 1987;317:781787. 6. Gardner JW, Kark JA: Fatal rhabdomyolysis presenting as mild heat illness in military training. Milit Med 1994;159:160-163. 7. Bergeron MF, Gannon JG, Hall EL, Kutlar A: Erythrocyte sickling during exercise and thermal stress. Clin J Sport Med 2004;14:354-356. 8. Eichner ER: Sickle cell trait and the athlete. Gatorade Sports Science Institute Sports Science Exchange 2006; 19(4):1-4. 9. Browne RJ, Gillespie CA: Sickle cell

trait: A risk factor for life-threatening rhabdomyolysis? Phys Sportsmed 1993;21(6):80-88. 10. Dincer HE, Raza T: Compartment syndrome and fatal rhabdomyolysis in sickle cell trait. Wisc Med J 2005;104:67-71. 11. Makaryus JN, Catanzaro JN, Katona KC: Exertional rhabdomyolysis and renal failure in patients with sickle cell trait: Is it time to change our approach? Hematology 2007;12:349-352. 12. Mitchell BL: Sickle cell trait and sudden death – bringing it home. J Nat Med Assn 2007;99:300-305.

Equipment Also found on the NCAA website at: NCAA.org/health-safety

GUIDELINE 4a

Protective Equipment June 1983 • Revised June 2007

Rules governing mandatory equipment and equipment use vary by sport. Athletics personnel should be familiar with what equipment is mandatory by rule and what constitutes illegal equipment; how to wear mandatory equipment during the contest; and when to notify the coaching staff that the equipment has become illegal during competition. Athletics personnel involved in sports with established

equipment standards should adhere to those standards.

its maintenance, the student-athlete also is complying with the purpose of the standard.

The NOCSAE mark on a helmet or HECC seal on an ice hockey face mask indicates that the equipment has been tested by the manufacturer in accordance with NOCSAE or HECC test standards. By keeping a proper fit, by not modifying its design, and by reporting to the coach or equipment manager any need for

The following list of mandatory equipment and rules regarding pro tective equipment use is based on NCAA sports rules. The most updated information should be obtained from relevant NCAA rules committees.

Sport

Mandatory Protective Equipment*

Rules Governing Special Protective Equipment

1. Baseball

1 . A double ear-flap protective helmet while batting, on deck and running bases. Helmets must carry the NOCSAE mark.

None

2 . All catchers must have a built-in or attachable throat guard on their masks.

3 . All catchers are required to wear a protective helmet when fielding their position.

2. Basketball

None Elbow, hand, finger, wrist or forearm guards, casts or braces made of fiberglass, plaster, metal or any other nonpliable substance shall be prohibited. Pliable (flexible or easily bent) material covered on all exterior sides and edges with no less than 0.5-inch thickness of a slowrebounding foam shall be used to immobilize and/or protect an injury. The prohibition of the use of hardsubstance material

Protective Equipment Sport

Mandatory Protective Equipment*

Basketball (continued)

Rules Governing Special Protective Equipment does not apply to the upper arm, shoulder, thigh or lower leg if the material is padded so as not to create a hazard for other players. Equipment that could cut or cause an injury to another player is prohibited, without respect to whether the equip ment is hard. Equipment that, in the referee’s judgment, is dangerous to other players, may not be worn.

3. Fencing 1. Masks with meshes (space

between the wires) of maximum 2.1 mm and from wires with a minimum gauge of 1 mm diameter. 2. Gloves, of which the gauntlet must fully cover approximately half the forearm of the competitor’s sword arm. 3. Jacket or vest and metallic lames. 4. Ladies’ chest protectors made of metal or some other rigid material. 5. Underarm protector.

4. Field Hockey

1. The following equipment is permitted for use only by goalkeepers: body and wrap-around throat protectors, pads, kickers, gauntlet gloves, helmet incorporating fixed full-face protection and cover for the head, and elbow pads. 2. Mouthguards for all players including goalkeepers. 3. Wrap-around throat protector and helmet for player designated as a “kicking back.” In the event of a defensive penalty corner, the “kicking back” must also wear a chest protector and distinguishing jersey.

Players shall not wear anything that may be dangerous to other players. Players have the option of wearing soft headgear subject to game official approval.

Protective Equipment

Sport 5. Football

Mandatory Protective Equipment*

Rules Governing Special Protective Equipment

1. Soft knee pads at least ½-inch thick must cover the knees and be covered by pants. No pads or protective equipment may be worn outside the pants. 2. Face masks and helmets with a secured four- or six-point chin strap. All players shall wear helmets that carry a warning label regarding the risk of injury and a manufacturer’s or reconditioner’s certification indicating satisfaction of NOCSAE test standards. 3. Shoulder pads, hip pads with tailbone protectors and thigh guards. 4. An intra-oral mouthpiece of any readily visible color (not white or transparent) with FDA-approved base materials (FDCS) that covers all upper teeth. It is recommended that the mouthpiece be properly fitted.

Illegal equipment includes the following: 1. Equipment worn by a player, including artificial limbs, that would endanger other players. 2. Hard, abrasive or unyielding substances on the hand, wrist, forearm or elbow of any player, unless covered on all exterior sides and edges with closed-cell, slowrecovery foam padding no less than ½-inch thick, or an alternate material of the same minimum thickness and similar physical properties. Hard or unyielding substances are permitted, if covered, only to protect an injury. Hand and arm protectors (covered casts or splints) are permitted only to protect a fracture or dislocation. 3. Thigh guards of any hard substances, unless all surfaces are covered with material such as closedcell vinyl foam that is at least ¼-inch thick on the outside surface and at least 3/8-inch thick on the inside surface and the overlaps of the edges; shin guards not covered on both sides and all edges with closed-cell, slowrecovery foam padding at least ½-inch thick, or an alternate material of the same minimum thickness having similar physical properties; and therapeutic or preventive knee braces, unless worn under the pants and entirely covered from direct external exposure.

Protective Equipment

Sport

Mandatory Protective Equipment*

Football (continued)

Rules Governing Special Protective Equipment 4. Projection of metal or other hard substance from a player’s person or clothing.

6. Gymnastics

None

7. Ice Hockey

1. Helmet with chin straps securely fastened. It is recommended that the helmet meet HECC standards. 2. An intra-oral mouthpiece that covers all the upper teeth. 3. Face masks that have met the standards established by the HECCASTM F 513-89 Eye and Face Protective Equipment for Hockey Players Standard.

1. The use of pads or protectors made of metal or any other material likely to cause injury to a player is prohibited. 2. The use of any protective equipment that is not injurious to the player wearing it or other players is recommended. 3. Jewelry is not allowed, except for religious or medical medals, which must be taped to the body.

8. Women’s Lacrosse

1. The goalkeeper must wear a helmet with face mask, separate throat protector, a mouth piece, a chest protector. 2. All field players shall wear properly an intra-oral mouthpiece that covers all upper teeth. 3. All field players shall wear protective eyewear that meets current ASTM lacrosse standards (effective January 1, 2005).

Protective devices necessitated on genuine medical grounds must be approved by the umpires. Closefitting gloves, nose guards, eye guards and soft headgear may be worn by all players. These devices must create no danger to other players.

9. Men’s Lacrosse

1. Protective helmet that carries the NOCSAE mark, equipped with face mask and chin pad, with a cupped four-point chin strap (high-point hookup). 2. Intra-oral mouthpiece that covers all the upper teeth and is yellow or any other highly visible color. 3. Protective gloves, shoulder pads, shoes and jerseys. Shoulder pads shall not be altered. 4. Throat protector and chest protector are required for the goalie.

1. A player shall not wear any equipment that, in the opinion of the official, endangers the individual or others. 2. The special equipment worn by the goalkeeper shall not exceed standard equipment for a field player, plus standard goalkeeper equipment, which includes shin guards, chest protectors and throat protectors.

Protective Equipment

Sport

Mandatory Protective Equipment*

10. Rifle Shooters and range personnel in the immediate vicinity of the range required to wear hearing protection during smallbore. Shooters urged to wear shatterproof eye protection.

11. Soccer Players shall wear shin guards under the stockings in the manner intend ed, without exception. The shin guards shall be professionally manu factured, age and size appropriate and not altered to decrease protection. The shin guards must meet NOCSAE standards. 12. Skiing

13. Softball

Rules Governing Special Protective Equipment None

1. A player shall not wear anything that is dangerous to another player. 2. Knee braces are permissible provided no metal is exposed. 3. Casts are permitted if covered and not considered dangerous. 4. A player shall not wear any jewelry of any type whatsoever. Exception: Medical alert bracelets or neck laces may be worn but must be taped to the body.

Helmets manufactured for ski racing None are required in all Alpine events and event training.

1. Catchers must wear foot-to-knee shin guards; NOCSAE-approved protective helmet with face mask and built-in or attachable throat guard; and chest protector. 2. A NOCSAE-approved double-ear flap protective helmet must be worn by players while batting, running the bases or warming-up in the on-deck circle.

Casts, braces, splints and protheses must be well-padded to protect both the player and opponent and must be neutral in color. If worn by pitcher, cannot be distracting on nonpitching arm. If worn on pitching arm, may not cause safety risk or unfair competitive advantage.

14. Swimming and Diving

None

Protective Equipment

Sport

Mandatory Protective Equipment*

None 15. Track and Field

16. Volleyball

None

17. Water Polo

Cap with protective ear guards.

18. Wrestling

Protective ear guard.

Rules Governing Special Protective Equipment 1. No taping of any part of the hand, thumb or fingers will be permitted in the discus and javelin throws, and the shot put, except to cover or protect an open wound. In the hammer throw, taping of individual fingers is permissible. Any taping must be shown to the head event judge before the event starts. 2. In the pole vault, the use of a forearm cover to prevent injuries is permissible. 1. It is forbidden to wear any object that may cause an injury or give an artificial advantage to the player, including but not limited to headgear, jewelry and unsafe casts or braces. Religious medallions or medical identifications must be removed from chains and taped or sewn under the uniform. 2. All jewelry must be removed. Earrings must be removed. Taping of earrings or other jewelry is not permitted. 3. Hard splints or other potentially dangerous protective devices worn on the arms or hands are prohibited, unless padded on all sides with at least Â˝-inch thick of slow rebounding foam. None 1. Anything that does not allow normal movement of the joints and prevents oneâ&#x20AC;&#x2122;s opponent from applying normal holds shall be barred. 2. Any legal device that is hard and abrasive must be covered and padded. Loose pads are prohibited. It is recommended that all wrestlers wear a protective mouth guard. 3. Jewelry is not allowed.

GUIDELINE 4b

Eye Safety in Sports January 1975 • Revised August 2001

Eye injuries in sports are relatively frequent, sometimes catastrophic, and almost completely preventable with the use of appropriate protective devices. A sports eye protector may be a spectacle, a goggle, a face-supported protector, or a protector attached to a helmet. It comes with or without lenses, is capable of being held securely in place, and may protect the face as well as the eyes. Some forms can be worn over regular glasses. Sports eye protectors are specially designed, fracture-resistant units that comply with the American Society for Testing and Materials (ASTM), or the National Operating Committee on Standards for Athletic Equipment (NOCSAE) standards for specific sports. Approximately one-third of all persons participating in sports require corrective lenses to achieve the visual acuity necessary for proper and safe execution of their particular sports activity. Athletes who need corrective eyewear for participation should use lenses and frames that meet the appropriate safety standards. At this time, polycarbonate plastic is the only clear lens material that has been tested for sports and is recommended for all sports with the potential for impact. Other impactresistant lens materials may be available in the near future. Contact lenses are not capable of protecting the eye from direct blows. Student-

athletes who wear contact lenses for corrective vision should wear appropriate sports safety eyewear for ocular protection. The American Academy of Opthalmology recommends that head, face and eye protection should be certified by either the Protective Eyewear Certification Council (PECC — www. protecteyes.org/), the Hockey Equipment Certification Council (HECC — www.hecc-hockey.org/), the National Operating Committee on Standards for Athletic Equipment (NOCSAE — www. nocsae.org/), or the Canadian Standards Association (CSA — www.csa-international.org/). The cited websites will have more specific information on these standards. Certification ensures that the protective device has been properly tested to current standards. Protective eyewear should be considered for all sports that have a projectile object (ball/stick) whose size and/or speed could potentially cause ocular damage. Eye protection is especially important for functionally one-eyed sports participants (whose best corrected vision in their weaker eye is 20/40 or worse). Eye protection devices are designed to significantly reduce the risk of injury, but can never provide a guarantee against such injuries.

Summary 1. Appropriate for eye protection in sports: a. Safety sports eyewear that conforms to the requirements of the American Society for Testing and Materials (ASTM) Standard F803 for selected sports (racket sports, basketball, women’s lacrosse, and field hockey). b. Sports eyewear that is attached to a helmet or is designed for sports for which ASTM F803 eyewear alone provides insufficient protection. Those for which there are standard specifications include: skiing (ASTM 659), and ice hockey (ASTM F513). Other protectors with NOCSAE standards are available for football and men’s lacrosse. 2. Not appropriate for eye protection in sports: a. Streetwear (fashion) spectacles that conform to the requirements of American National Standards Institute (ANSI) Standard Z80.3. b. Safety eyewear that conforms to the requirements of ANSI Z87.1, mandated by OSHA for industrial and educational safety eyewear.

Eye Safety in Sports

References

1. Prevent Blindness America: 1998 Sports and Recreational Eye Injuries. Schaumburg, IL: Prevent Blindness America; 1999. 2. Napier SM, Baker RS, Sanford DG, et al.: Eye Injuries in Athletics and Recreation. Survey of Opthalmology. 41:229-244, 1996. 3. Vinger PF: The Eye and Sports Medicine.In Duane TD, Jaeger EA (eds): Clinical Ophthalmology, vol. 5, chapter 45, J.B. Lippincott, Philadelphia, PA 1994.

4. Vinger PF, Parver L, Alfaro DV, Woods T, Abrams BS. Shatter resistance of spectacle lenses. JAMA 1997; 277:142-144. 5. Vinger PF. A practical guide for sports eye protection. Physician and Sportsmedicine, 2000;28;49-69. 6. Play hardâ&#x20AC;&#x201D;play safe. San Francisco, CA: American Academy of Ophthalmology, 2001.

GUIDELINE 4c

Mouthguards January 1986 • Revised August 2007

The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Dr. Jack Winters, past president of the Academy of Sports Dentistry, in the revision of this guideline. The NCAA has mandatory equipment rules, including the use of mouthguards for selective sports. Various studies of “properly fitted mouthguards” indicate that they may reduce dental injuries when blows to the jaws or head are received. The American Dental Association has urged the mandatory use of mouthguards for those engaged in athletics activities that involve body contact and endorsed their use “in sporting activities in which a significant risk of oral injury may occur.” It is important when considering the optimum protection for an athlete that a thorough medical history be taken and the demands of his or her position and sporting activity be considered. Specific objectives for the use of “properly fitted mouthguards” as protective devices in sports are as follows:

1. “Properly fitted mouthguards” could reduce the potential chipping of tooth enamel surfaces and reduce fractures of teeth, roots or bones.

2. “Properly fitted mouthguards” could protect the lip and cheek tissues from being impacted and lacerated against tooth edges. 3. “Properly fitted mouthguards” could reduce the incidence of a fractured jaw caused by a blow delivered to the chin or head. 4. “Properly fitted mouthguards” could provide protection to toothless spaces, so support is given to the missing dentition of the student-athlete. Stock, mouth-formed and customfitted are three types of mouthguards recognized by the American Dental Association. All need to be properly fitted for maximum protection. Studentathletes should be advised as to which “properly fitted mouthguard” is best for them and how it is best maintained to ensure the maximum fit and protection for daily practices and game-day wear. Medical staff personnel should regularly oversee and observe the student-athletes and the “properly fitted mouthguards.” In order to realize fully the benefits of wearing a mouthguard, the coach, student-athlete and medical staff need to be educated about the protective functions of a mouthguard and the game rules regarding mouthguard use must be enforced.

Mouthguards Sport

Position

Intra-oral Mouthguard

Color

Covers All Upper Teeth

Field Hockey Field Mandatory (NCAA Mod. 8.1.b); Not specified Not specified strongly recommended for goalkeepers Football All Mandatory (NCAA 1.4.4.d) Readily Visible Color Yes (not white or transparent) Ice Hockey All Mandatory (NCAA 3.2) Recommended

When Regular Season Competition and NCAA Championships

Regular Season Competition, Postseason Competition and NCAA Championships

Covers all the Regular Season remaining teeth Competition and of one jaw. NCAA Championships

Women’s All Mandatory (NCAA 2.8) Not specified Yes Lacrosse

Regular Season Competition and NCAA Championships

Men’s Lacrosse All Mandatory (NCAA 1.20) Yellow or any Yes other visible color

Regular Season Competition and NCAA Championships

References

1. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. American Dental Association. 2006. 2. Kumamoto, D and Maeda, Y. A literature review of sports-related orofacial trauma. General Dentistry. 2004:270-281. 3. Bourdin M, Brunet-Patru I, Hager P, Allard Y, Hager J, Lacour J, Moyen B. 2006. Influence of maxillary mouthguards on

physiological parameters. MSSE. (38)8: 1500-1504. 4. Academy for Sports Dentistry. “Position Statement: ‘A Properly Fitted Mouthguard’ Athletic Mouthguard Mandates.” Available at www.acadsportsdent.org. 5. Stenger, J.M. (1964). “Mouthguards: Protection Against Shock to Head, Neck and Teeth.” Journal of the American Dental Association. Vol. 69 (3). 273-281. 6. “Sports Dentistry.” (1991,

October. Revised 2000, April). Dental Clinics of North America. 7. American Dental Association. (1999). “Your Smile with a Mouthguard.” (211 East Chicago Avenue, Chicago, IL, 60611) 8. Winters, J.E. (1996, June). “The Profession’s Role in Athletics.” Journal of the American Dental Association. Vol. 127. 810-811.

GUIDELINE 4d

Use of the Head as a Weapon in Football and Other Contact Sports January 1976 • Revised June 2002

Head and neck injuries causing death, brain damage or paralysis occur each year in football and other sports. While the number of these injuries each year is relatively small, they are devastating occurrences that have a great impact. Most of these catastrophic injuries result from initiating contact with the head. The injuries may not be prevented due to the forces encountered during collisions, but they can be minimized by helmet manufacturers, coaches, players and officials complying with accepted safety standards and playing rules. The American Football Coaches Association, emphasizing that the helmet is for the protection of the wearer and should not be used as a weapon, addresses this point as follows: 1. The helmet shall not be used as the

brunt of contact in the teaching of blocking or tackling; 2. Self-propelled mechanical apparatuses shall not be used in the teaching of blocking and tackling; and 3. Greater emphasis by players, coaches and officials should be placed on eliminating spearing. Proper training in tackling and blocking techniques, including a “see what you hit approach,” constitutes an important means of minimizing the possibility of catastrophic injury. Using the helmet as an injury-

inflicting instrument is illegal, and should be strongly discouraged by coaches and game officials. This concern is not only in football, but also in other contact sports in which helmets are used (e.g., ice hockey and men’s lacrosse). Football and all contact sports should be concerned with the prevention of catastrophic head injuries. The rules against butting, ramming and spearing with the helmet are for the protection of the helmeted player and the opponent. A player who does not comply with these rules in any sport is a candidate for a catastrophic injury.

1. NCAA Concussion Fact Sheets and Video Available at www.NCAA.org/health-safety.

2. Heads Up: Concussion Tool Kit CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.

3. Heads Up Video NATA. Streaming online at www.nata.org/consumer/headsup.htm.

References

100

1. Kleiner, D.M., Almquist, J.L., Bailes, J., Burruss, P., Feurer, H., Griffin, L.Y., Herring, S., McAdam, C., Miller, D., Thorson, D., Watkins, R.G., Weinstein, S. Prehospital Care of the Spine-Injured Athlete: A Document from the InterAssociation Task Force for Appropriate Care of the Spine-Injured Athlete. Dallas, National Athletic Trainers’ Association, March, 2001.

2. LaParade RF, Schnetzler KA, Broxterman RJ, Wentorf F, Wendland E, Gilbert TJ: Cervical Spine Alignment in the Immobilized Ice Hockey Player: A Computer Tomographic Analysis of the Effects of Helmet Removal: Am J Sports Med 27: 177-180, 1999. 3. The Spine Injury Management Video Human Kinetics, Champaign, Illinois.

4. Thomas BE, McCullen GM, Yuan HA: Cervical Spine Injuries in Football Players: J Am Acad Orthop Surg SeptOct; 7 (5), 338-47, 1999. 5. Wojtys EM, Hovda D, Landry G, Boland A, Lovell M, McCrea M, Minkoff J: Concussion in Sports: Am J Sports Med 27: 676-687, 1999.

GUIDELINE 4e

Guidelines for Helmet Fitting and Removal in Athletics June 1990 • Revised June 2006

Several sports, including football, men’s lacrosse and ice hockey, require wearing tight-fitting, similarly constructed helmets. The following guidelines, while focused on football, are applicable to periodic evaluation, fitting and removal of protective helmets worn in any sport. These guidelines represent minimal standards of care that are designed to assist physicians, coaches, athletic trainers, paramedics, EMTs and hospital personnel who care for student-athletes. Medical coverage of interscholastic and intercollegiate teams entails many routine preventive and acute health-care duties for dedicated practicing professionals; however, an occasional, serious, on-the-field, life-threatening head and/or neck injury poses a difficult challenge. It is incumbent upon those individuals assigned to provide medical coverage to be prepared to handle each situation efficiently and expertly. Proper on-the-field management of head and neck injuries is essential to minimize sequelae, expedite emergency measures and to prepare for transportation. The action of those in attendance must not compound the problem. For this reason, clear communication

between the medical staff and emergency-transportation personnel should be maintained. It is important that those involved in the medical management of teams engaged in collision and contact sports, and the student-athlete be knowledgeable about the helmet. The student-athlete should be instructed in the fitting, care and use of the helmet. Helmet manufacturer guidelines should be reviewed and followed for proper fitting and care techniques. The resilient plastic shell is shaped spherically to deflect impacts. Interior suspension pads are designed to match the skull contour to ensure a snug crown fit. Various rigid and removable jaw and brow pads, along with the chin strap, help to hold the sides of the helmet firmly against the mandible and the forehead. When in place, the front edge of the helmet should be positioned about a finger’s breadth above the eyebrows. Pressure on the helmet crown should be dissipated through the interior suspension padding over the top of the head. The helmet should fit snugly without dependence on the chin strap. The helmet should not twist or slide when an examiner grasps the face mask and attempts to rock

or turn the helmet with the wearer resisting the movement. With a properly fitted helmet, the top of the head is separated from the helmet shell by a uniform, functional, shock-absorbing support lining. Daily evaluation of this support mechanism, including cheek and brow pads, for placement and resiliency should be taught to the student-athlete. Hel mets that require air inflation should be inflated and inspected daily by those assigned to equipment care. Helmet shells should be examined weekly for cracking and be inspected closely again if the face mask has been bent out of shape. All helmets need to be reconditioned and the attachments of the mask replaced on a yearly basis. Although the helmet is designed for a stable fit for protection during play, removal of the helmet by others is relatively difficult. In the case of a head or neck injury, jostling and pulling during removal presents high potential for further trauma. Unless there are special circumstances such as respiratory distress coupled with an inability to access the airway, the helmet should never be

101

Guidelines for Helmet Fitting and Removal in Athletics removed during the pre-hospital care of the student-athlete with a potential head/neck injury unless: 1. The helmet does not hold the head securely, such that immobilization of the helmet does not immobilize the head; 2. The design of the sport helmet is such that even after removal of the facemask, the airway cannot be controlled or ventilation provided; 3. After a reasonable period of time, the facemask cannot be removed; or 4. The helmet prevents immobilization for transportation in an appropriate position. When such helmet removal is necessary in any setting, it should be performed only by personnel trained in this procedure. Ordinarily, it is not necessary to remove the helmet on the field to evaluate the scalp. Also, the helmet can be left in place when evaluating an unconscious student- athlete, an individual who demonstrates transient or persistent neurological findings in his/her extremities, or the student-athlete who complains of continuous or transient neck pain.

102

Before the injured student-athlete is moved, airway, breathing and circulation (ABCs) should be evaluated by looking, listening and palpation. To monitor breathing, care for facial injury, or before transport regardless of current respiratory status, the facemask should be removed by cutting or unscrewing the loops that attach the mask to the helmet. These

loops may be difficult to cut, necessitating the use of PVC pipe cutters, garden shears or a screwdriver. Those involved in the pre-hospital care of the injured student-athlete should have readily available proper tools for easy facemask removal and should frequently practice removal techniques for facemasks and helmets. It should be noted that cold weather and old loops may make cutting difficult. The chin strap can be left in place unless resuscitative efforts are necessary. For resuscitation, the mouthpiece needs to be manually removed. Once the ABCs are stabilized, transportation to an emergency facility should be conducted with the head secure in the helmet and the neck immobilized by strapping, taping and/or using lightweight bolsters on a spine board. When moving an athlete to the spine board, the head and trunk should be moved as a unit, using the lift/slide maneuver or a log-roll technique. At the emergency facility, satisfactory initial skull and cervical X-rays usually can be obtained with the helmet in place. Should removal of the helmet be needed to initiate treatment or to obtain special X-rays, the following protocol should be considered: • With the head, neck and helmet manually stabilized, the chin strap can be cut. • While maintaining stability, the cheek pads can be removed by slipping the flat blade of a screwdriver or bandage scissor under the pad snaps and above the inner surface of the shell. • If an air cell-padding system is present, it can be deflated by releasing the air at the external port with an inflation needle or large-

gauge hypodermic needle. • By rotating the helmet slightly forward, it should now slide off the occiput. If the helmet does not move with this action, slight traction can be applied to the helmet as it is carefully rocked anteriorly and posteriorly, with great care being taken not to move the head/neck unit. • The helmet should not be spread apart by the earholes, as this maneuver only serves to tighten the helmet on the forehead and on the occipital regions. • All individuals participating in this important maneuver must proceed with caution and coordinate every move. If the injured student-athlete, after being rehabilitated fully, is allowed to participate in the sport again, refitting his/her helmet is mandatory. Re-education about helmet use as protection should be conducted. Using the helmet as an offensive, injury-inflicting instrument should be discouraged.

Guidelines for Helmet Fitting and Removal in Athletics

References

1. Anderson C: Neck Injuries—Back board, bench or return to play? The Physician and Sports Medicine 21(8): 23-34, 1993. 2. Guidelines for Helmet Fitting and Removal in Athletics. Illinois State Medical Society, 1990. (20 North Michigan Avenue, Chicago, Illinois 60602) 3. Inter-Association Task Force for the

Cervical Spine. National Athletic Trainers’ Association, 2000. (2952 Stemmons Free way, Dallas, Texas 75247, www.nata.org) 4. AOSSM Helmet Removal Guidelines. The American Orthopedic Society for Sports Medicine. (6300 N. River Road, Suite 200, Rosemont, Illinois 60018 www.sportsmed.org). 5. The Hockey Equipment Certification Council Inc. www.hecc.net.

6. US Lacrosse. www.uslacrosse.org. Lacrosse Helmet Facemask/Chinguard Removal Hints for Certified Athletic Trainers. US Lacrosse, 2008. Available at www.uslacrosse.org/safety. 7. National Operating Committee on Standards for Athletic Equipment (NOCSAE). www.nocsae.org.

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GUIDELINE 4f

Use of Trampoline and Minitramp June 1978 • Revised June 2002

The NCAA recognizes that the coaches and student-athletes in selected sports use the trampoline and minitramp for developing skills. The apparent safety record accompanying such use has been good, but the use of the trampoline can be dangerous. Therefore, these guidelines should be followed in those training activities in which student-athletes use the trampoline: 1. Trampolines should be supervised by persons with competence in the use of the trampoline for developing athletics skills. This implies that: a. Fellow coaches, studentathletes, managers, etc., are trained in the principles and techniques of spotting with the overhead harness, “bungee system” and/or hand spotting on the trampoline; b. New skills involving somersaults should be learned while wearing an overhead safety harness. (Exception: Use of the overhead system is not recommended for low-level salto activities such as saltos from the knees or back.) Those

104

persons controlling the safety harness should have the necessary strength, weight and training for that responsibility;

and name of inspector, should be kept on file.

c. Skills being encouraged should be commensurate with the readiness of the studentathlete, and direct observation should confirm that the studentathlete is not exceeding his or her readiness; and

The minitramp, while different in nature and purpose from the trampoline, shares its association with risk of spinal cord injury from poorly executed and/or spotted tricks. Like the trampoline, the minitramp requires competent instruction and supervision, spotters trained for that purpose (spotting somersaults on the minitramp differs from the trampoline because of the running action preceding the somersault), emphasis on the danger of somersaults and dive rolls, security against unsupervised use, proper erection and maintenance of the apparatus, a planned procedure for emergency care should an accident occur, and documentation of participation and any accidents that occur. In addition, no single or multiple somersault should be attempted unless:

d. Spotters are aware of the particular skill or routine being practiced and are in an appropriate position to spot potential errors. Accurate communication is important to the successful use of these techniques. 2. Potential users of the trampoline should be taught proper procedures for folding, unfolding, transporting, storing and locking the trampoline. 3. The trampoline should be erected in accordance with manufacturer’s instructions. It should be inspected regularly and maintained according to established standards. All inspection reports, including the date of inspection

Minitramp

1. The student-athlete has demonstrated adequate progression of skill before attempting any

Use of Trampoline and Minitramp somersault (i.e., on the trampoline with a safety harness, off a diving board into a swimming pool or tumbling with appropriate spotting); 2. One or more competent spotters who know the skill being attempted are in position and are physically capable of spotting an improper execution; 3. The minitramp is secured reasonably or braced to prevent slipping at the time of execution in accordance with recommendations in the USA Gymnastics Safety Handbook; and 4. A mat is used that is sufficiently wide and long to prevent the performer from landing on the matâ&#x20AC;&#x2122;s edge and to provide proper footing for the spotter(s).

References

1. American Alliance for Health, Physical Education, Recreation and Dance: The use of the trampoline for the development of competitive skills in sports. Journal of Physical Education, Recreation and Dance 49(8):14, 1978. 2. Hennessy JT: Trampoline safety and diving programs. U.S. Diving Safety Manual. Indianapolis, IN: U.S. Diving Publications, 1990. 3. Larson BJ, Davis JW. Trampoline-

related injuries. J Bone Joint Surg Am. 1995; 77:1174-1178. 4. Trampolines at Home, School and Recreational Centers Policy Statement of the American Academy of Pediatrics. Pediatrics Vol. 103 (5) 1999 pp. 10531056. (www.aop.org/policy/re9844.html). 5. USA Gymnastics: USA Gymnastics Safety Handbook, 1994. (201 S. Capitol St., Ste. 300, Indianapolis, IN 46225)

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Appendixes Also found on the NCAA website at: NCAA.org/health-safety

Appendix A

NCAAâ&#x20AC;&#x2C6;Legislation Involving Health and Safety Issues This chart should be used as a quick reference for NCAA legislation involving health and safety issues that appears in the 2010-11 NCAA Divisions I, II and III Manuals. The comment section does not capture the full scope of the legislation; users are encouraged to review the full bylaw in the appropriate divisional manual. Because of the dynamic nature of the NCAA legislative process, the most current information on these and any new legislation should be obtained through the institution's athletics department compliance staff.

Regulations Involving Health and Safety Issues Topic Issue

Banned Drugs

108

NCAA Bylaw Cite

Comments

List of Banned Drug Classes

31.2.3.4

Lists all drug classes currently banned by the NCAA.

Drugs and Procedures Subject to Restrictions

31.2.3.4.1

List of drugs and procedures that are restricted.

Effect on Eligibility

18.4.1.5

A positive test for use of a banned (performance enhancing or "street") substance results in loss of eligibility.

Effect on Championship Eligibility

18.4.1.5

A positive test for a banned (performance enhancing or "street") substance results in loss of eligibility, including eligibility for participation in postseason competition.

Transfer While Ineligible Due to Positive Drug Test

13.1.1.3.5 (Div. I), 13.1.1.2.4 (Div. II), 13.1.1.2.6 (Div. III)

Institution at which student-athlete tested positive for use of a banned substance must report the test result to the institution to which the student-athlete is transferring.

Knowledge of Use of Banned Drugs

10.2

Athletics department staff members or others employed by intercollegiate athletics department with knowledge of a studentathlete's use of a banned substance must follow institutional policies.

NCAA Legislation Involving Health and Safety Issues

Drug Testing

Drug Rehabilitation

Nutritional Supplements

Banned Drugs and Drug-Testing Methods

18.4.1.5.2

NCAA Executive Committee is charged with developing a list of banned substances and approving all drug-testing procedures.

Consent Form: Content and Purpose

14.1.4.1

Consent must be signed before competition or practice or before the Monday of fourth week of classes. Failure to sign consent results in loss of eligibility.

Consent Form: Administration

14.1.4.2, 3.2.4.7 (Div. I); 14.1.4.2, 3.2.4.6 (Div. II); 14.1.4.2, 3.2.4.6 (Div. III)

Institution must administer consent form to all student-athletes each academic year at the time the intercollegiate squads report for practice. At this time, institutions must also distribute to student-athletes the list of banned drug classes.

Consent Form: Exception, 14-Day Grace Period

14.1.4.3 (Div. I) 14.1.4.2 (Div. II)

Student-athletes who are trying out must sign the form within 14 days of the first 足athleticsrelated activity or before they 足compete, whichever occurs first.

Effect of Non-NCAA Athletics Organization's Positive Drug Test

18.4.1.5.3

A student-athlete under a drug-test suspension from a national or international sports governing body shall not compete in NCAA intercollegiate competition.

Failure To Properly Administer Drug-Testing Consent Form (Div. I and Div. II only)

14.1.4.4

Failure to properly administer drug-testing consent form is considered an institutional violation.

Drug Rehabilitation Program Expenses

16.4.1 (Div. I and Div. II), 16.4 (Div. III)

Permissible for institution to cover the costs of a student-athlete's drug rehabilitation program.

Travel To and From Drug Rehabilitation Program

16.12.1

Permissible to file a waiver under Bylaw 16.12.1 to cover costs associated with a drug rehabilitation program.

Permissible Supplements

16.5.2(g) (Div. I), 16.5.1(h) (Div. II)

Institution may provide only permissible nutritional supplements that do not contain any NCAA banned substances. See Bylaw for details.

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NCAA Legislation Involving Health and Safety Issues

Tobacco Use

Restricted Advertising and Sponsorship Activities

31.1.14.1 (Div. I), 31.1.12.1 (Div. II and Div. III)

Tobacco Use at Member Institution

11.1.5 (Div. Use of tobacco products is prohibited by all I and Div. II), game personnel and all student-athletes in all 17.1.8 (Div. I), sports during practice and competition. 17.1.9 (Div. II), 17.1.11 (Div. III)

Permissible Medical Expenses

Permissible medical expenses are outlined. If 16.4.1 expense is not on the list, refer to Bylaw (Div. I and Div. II), 16.4 16.12.1 for waiver procedure. (Div. III)

Eating Disorders (Div. I and Div. II only)

16.4.1

Institution may cover expenses of counseling related to the treatment of eating disorders.

Transportation for Medical Treatment (Div. I and Div. II only)

16.4.1

Institution may cover or provide transportation to and from medical appointments.

Summer Conditioning - Football

13.2.7

Summer Conditioning - Sports other than Football (Div. I only)

13.2.8

Institution may finance medical expenses for a prospect who sustains an injury while participating in nonmandatory summer conditioning activities that are conducted by an institution's strength and conditioning coach.

Hardship Waiver

14.2.4 (Div. I), 14.2.5 (Div. II and Div. III)

Under certain circumstances, a student-athlete may be awarded an additional season of competition to compensate for a season that was not completed due to incapacitating injury or illness.

Five-Year/10-Semester Rule Waiver

14.2.1.5.1 (Div. I), 14.2.2.3 (Div. II and Div. III)

Under certain circumstances, a student-athlete may be awarded an additional year of eligibility if he or she was unable to participate in intercollegiate athletics due to incapacitating physical or mental circumstances.

HIPAA/Buckley Amendment Consent Forms

3.2.4.9, 14.1.6 (Div. I); 3.2.4.7, 14.1.5 (Div. II); 3.2.4.7, 14.1.6 (Div. III)

The authorization/consent form shall be administered individually to each studentathlete by the athletics director or the athletics director's designee before the student-athlete's participation in intercollegiate athletics each academic year. Signing the authorization/ consent shall be voluntary and is not required by the student-athlete's institution for medical treatment, payment for treatment, enrollment in a health plan or for any benefits (if applicable) and is not required for the studentathlete to be eligible to participate. Any signed authorization/consent forms shall be kept on file by the director of athletics.

Medical Expenses

Medical Waivers

Medical Records and Consent Forms

110

No tobacco advertisements in, or sponsorship of, NCAA championships or regular-season events.

NCAA Legislation Involving Health and Safety Issues

Student-Athlete Welfare and Safety

Time Restrictions on AthleticsRelated Activities

17.1.6

All NCAA sports are subject to the time limitations in Bylaw 17.

Daily/Weekly Hour Limitation – Inside Playing Season (Div. I and Div. II only)

17.1.6.1

During the playing season, a student-athlete cannot engage in more than 20 hours of athletics-related activity (see Bylaw 17.02.1) per week, with not more than four hours of such activity in any one day.

Weekly Hour Limitations – Outside Playing Season (Div. I and Div. II only)

17.1.6.2

Outside of the playing season, student-athletes cannot engage in more than eight hours of conditioning activities per week.

Skill Instruction Exception (Div. I and Div. II only) See Bylaws 17.1.6.2.2 and 17.1.6.2.3 (Div. I) for additional exceptions.

17.1.6.2.2, 17.1.6.2.3 (Div. I), 17.1.6.2, 17.1.6.2.1 (Div. II)

Outside of the playing season, two of the student-athlete's eight hours of conditioning activity may be skill-related instruction with coaching staff.

Required Day Off – Playing Season

17.1.6.4 (Div. I and Div. II), 17.1.6 (Div. III)

During the playing season, each studentathlete must be provided with one day per week on which no athletics-related activities are scheduled.

Required Days Off – Outside Playing Season (Div. I and Div. II only)

17.1.6.5

Outside the playing season, each studentathlete must be provided with two days per week on which no athletics-related activities are scheduled.

Voluntary Summer Conditioning – (Div. I only)

13.11.3.9 (basketball)

Prospective student-athletes, who signed an NLI or enrolled in the institution's summer term prior to initial, full-time enrollment, may engage in voluntary summer workouts conducted by an institution's strength and conditioning coach with department-wide duties.

Voluntary Summer Conditioning – (Div. I only)

13.11.3.8 (football)

Sports-Safety Training

11.1.6 (Div. II)

Each head coach and all other coaches who are employed full time at an institution shall maintain current certification in first aid, cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use.

11.1.6 (Div. III)

Each head coach shall maintain current certification in first aid, cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use.

111

NCAA Legislation Involving Health and Safety Issues

Student-Athlete Welfare and Safety

112

Discretionary Time (Div. I only)

17.02.14

Student-athletes may only participate in athletics activities at their initiative during discretionary time.

Mandatory Medical Examinations

17.1.5

All student-athletes beginning their initial season of eligibility and students who are trying out for a team must undergo a medical exam before they are permitted to engage in any physical activity. The exam must take place within six months before the physical activity. Each subsequent year, an updated medical history must be administered by an institutional medical staff member.

17.1.5.1 (Div. I)

The examination or evaluation of studentathletes who are beginning their initial season of eligibility and students who are trying out for a team shall include a sickle cell solubility test, unless documented results of a prior test are provided to the institution or the prospective student-athlete or student-athlete declines the test and signs a written release.

Five-Day Acclimatization Period – Football

17.9.2.3 (Div. I), 17.9.2.2 (Div. II and Div. III)

Five-day acclimatization for conducting administrative and initial practices is required for first-time participants (freshmen and transfers) and continuing student-athletes.

Preseason Practice Activities – Football

17.9.2.4 (Div. I), 17.9.2.3 (Div. II and Div. III)

Preseason practice time limitations and general regulations.

Out-of-Season Athletics-Related Football Activities

17.9.6 (Div. I and Div. III), 17.9.8 (Div. II)

Permissible summer conditioning activities.

Sport-specific Safety Exceptions (Equestrian; Fencing; Gymnastics; Rifle; Women’s Rowing; Skiing; Swimming; Track and Field; Water Polo; and Wrestling.) (Div. I and Div. II only)

13.11.3.11 (Div. I); 17.6.7; 17.7.7; 17.11.7; 17.14.7; 17.15.9; 17.18.7; 17.24.7; 17.26.8; 17.27.7

A coach may be present during voluntary individual workouts in the institution’s regular practice facility (without the workouts being considered as countable athletics-related activities) when the student-athlete uses sportspecific equipment. The coach may provide safety or skill instruction but cannot conduct the individual’s workouts.

Playing Rules Oversight Panel

21.1.6.1

The panel shall be responsible for resolving issues involving player safety, financial impact or image of the game.

Appendix B

NCAA Injury Surveillance Program Summary The NCAA Injury Surveillance Program was developed in 1982 to provide current and reliable data on injury trends in intercollegiate athletics. It collects injury and activity information in order to identify and highlight potential areas of concern and interest related to studentathlete health and safety. Injury data are collected yearly by the Datalys Center from a sample of NCAA member institutions, and the resulting data summaries are reviewed by the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. The committee’s goal continues to be to reduce injury rates through suggested changes in rules, protective equipment or coaching techniques, based on the data. In some instances, the evaluation of the injury surveillance information has led the NCAA to commission research studies to better understand the underlying factors that have contributed to the observed surveillance findings. To support the objective and nature of the NCAA’s Injury Surveillance Program – monitoring to identify areas of concern for potential further investigation – the Datalys Center does not collect identifiable information or treatment information.

Program Benefits Participation in the NCAA’s Injury

Surveillance Program supports rule and policy changes that improve student-athlete health and safety. In addition, program participation provides a number of benefits to athletic trainers and their institutions: Safer participation in collegiate sports – In some cases, surveillance information has led to a mitigation of injuries and treatments (e.g., heat illness episodes). Resource Justification and Allocation – Surveillance information has been used in the NATA’s Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics (AMCIA) document. Supports Clinical Best Practices Regional and national injury rate comparisons allow a university to explore relevant clinical best practices with appropriate peer groups. Supports Risk Management Best Practice – The electronic documentation of injuries (e.g., through an Export Engine Certified vendor or the Injury Surveillance Tool) is a recognized risk management best practice. Facilitates Paper Record Keeping Processes – For institutions managing their health records via a paper process, the Injury Surveillance Tool facilitates the workflow and supports an enhanced level of documentation and record keeping.

Two easy ways to participate: The Injury Surveillance Tool (IST) facilitates the workflow in the athletic training room and supports an enhanced level of documentation and record keeping. The IST is designed as a free injury incident report, and allows documentation of injuries. In doing so, the IST provides important injury information to the Datalys Center and helps to initiate a paper record keeping process for the athletic trainer. The Export Engine Program (EE) is a public data transmission standard that commercial vendors can voluntarily adopt. Through the Export Engine Program, athletic trainers can directly and easily submit data from their vendor systems to the Injury Surveillance Program. If you are considering a new system, be sure to look for the Datalys Certified logo. Its certified vendors currently include ATS, Nextt Solutions and SIMS. Data Availability and Access Injury surveillance data collected through the NCAA’s Injury Surveillance Program is available to the public through the Datalys Injury Statistics Clearinghouse (DISC), a web-based research portal. DISC provides a searchable Document Library for published reports and data on sports injuries. DISC also provides an interactive Query Tool for public use that

113

NCAA Injury Surveillance System Summary

allows registered users to interactively query available datasets for summary information, such as national injury rates, injury rates by sports, and injury rates by type of injury. DISC will be launched in the fall of 2010 and can be found at www.disc. datalyscenter.org.

Sampling Since its inception, the surveillance program has depended on a volunteer â&#x20AC;&#x153;convenience sampleâ&#x20AC;? of reporting schools. Participation is available to the population of institutions sponsoring a given sport. Schools qualifying for inclusion in the final sample are selected from the total participating schools for each NCAA sport, with the goal of representation of all three NCAA divisions. A school is selected as qualifying for the sample if they meet the minimum standards for data collection. It is important to recognize that this system does not identify every injury that occurs at NCAA institutions in a particular sport. Rather, the emphasis is collecting all injuries and exposures from schools that voluntarily participate in the Injury Surveillance Program. The Injury Surveillance Program attempts to balance the dual needs of maintaining a reasonably representative cross-section of NCAA institutions while accommodating the needs of the voluntary participants.

Injuries A reportable injury in the Injury Surveillance Program is defined as one that: 1. Occurs as a result of participation in an organized intercollegiate practice or competition; and

114

2. Requires medical attention by a team athletic trainer or physician regardless of time loss.

Exposures (Activity)

All Sports Figures

An athlete exposure is defined as one athlete participating in one practice or competition in which he or she is exposed to the possibility of athletics injury.

The following figures outline selected information from the sports currently reported by the NCAA Injury Surveillance Program from 2004 to 2009. Complete summary reports for each sport are available online at www.disc. datalyscenter.org.

Injury Rate An injury rate is simply a ratio of the number of injuries in a particular category to the number of athlete exposures in that category. This value is expressed as injuries per 1,000 athlete exposures.

Historical Data The NCAA published 16 years of injury data in 15 sports in the Journal of Athletic Training National Collegiate Athletic Association Injury Surveillance, 1988-1989 Through 2003-2004. J Athl Train. 2007;42(2).

Any questions regarding the NCAA Injury Surveillance Program or its data reports should be directed to: Megan McGrath, Manager of Collegiate Engagement, Datalys Center for Sports Injury Research and Prevention, Indianapolis, Indiana (317/238-7040). David Klossner, Director of Educational Affairs, NCAA, P.O. Box 6222, Indianapolis, Indiana 46206-6222 (317/917-6222).

Figure 1 Competition and Practice Injury Rates Summary (All Sports) Men’s Football 48.1

7.0 Men’sWrestling 24.3

9.7 Men’s Ice Hockey

24.0

3.3 Men’s Soccer

23.6

7.1 Women’s Soccer

Practice Injury Rate Competition Injury Rate

21.7

7.4

Figure 1 represents the average injury rates for all sports from 2004-2009, unless otherwise noted below. *Sports with data from 2005-06 to 2008-09 (4 years only). **Sports with data from 2006-07 to 2008-09 (3 years only).

Men’s Lacrosse 20.8

5.9 Women’s Gymnastics 18.4

9.8 Women’s Field Hockey 14.8

7.5 Men’s Basketball

14.3

6.3 Women’s Ice Hockey

13.7

3.5 Women’s Basketball

12.3

6.1 Women’s Lacrosse 8.8 3.9

Women’s Cross Country* 8.7 4.4 Women’s Volleyball 7.6

8.6

Men’s Cross Country* 7.7 4.3 Men’s Baseball 7.6 3.1 Women’s Softball 6.2 4.8 Women’s Swimming & Diving** 2.3 2.5 Men’s Swimming & Diving** 1.6 2.2

Injury Rate (per 1,000 A-E)

115

Figure 2 Percentage of All Injuries Occurring in Practices and Competition Women’s Swimming & Diving**

87.4

Men’s Cross Country*

87.1

12.6 12.9

Men’s Swimming & Diving**

86.0

14.0

Women’s Cross Country*

85.0

15.0

Women’s Gymnastics

81.4

Women’s Volleyball

71.4

Wrestling

Figure 2 represents the national estimates of injury percentages for all sports from 20042009, unless otherwise noted below.

18.6 28.6

70.4

* Sports with data from 2005-06 to 2008-09 (4 years only). **Sports with data from 2006-07 to 2008-09 (3 years only).

29.6

Women’s Lacrosse

64.1

36.0

Men’s Basketball

63.6

36.4

Women’s Basketball

63.3

36.7

Practice Field Hockey

61.6

38.4

Football

61.2

38.8

Men’s Lacrosse

60.0

40.0

Softball

51.9

48.1

Men’s Soccer

51.4

48.6

Women’s Soccer

51.3

48.8

Baseball

45.0

Women’s Ice Hockey

55.0

43.8

56.3

Men’s Ice Hockey 31.5

68.5

Percentage of All Injuries

116

Competition

100

Appendix C

Acknowledgements From 1974 to 2009, the following individuals have served on the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and contributed to the information in the NCAA Sports Medicine Handbook: John R. Adams Western Athletic Conference Ken Akizuki University of San Francisco James R. Andrews, M.D. Troy University Elizabeth Arendt, M.D. University of Minnesota, Twin Cities William F. Arnet University of Missouri, Columbia James A. Arnold University of Arkansas, Fayetteville Janet Kay Bailey Glenville State College Dewayne Barnes Whittier College Amy Barr Eastern Illinois University Fred L. Behling Stanford University Daphne Benas Yale University John S. Biddiscombe Wesleyan University (Connecticut) Carl S. Blyth University of North Carolina, Chapel Hill Cindy D. Brauck Missouri Western State College Donald Bunce, M.D. Stanford University Elsworth R. Buskirk Pennsylvania State University Peter D. Carlon University of Texas, Arlington Gene A. Carpenter

Millersville University of Pennsylvania Marino H. Casem Southern University, Baton Rouge Nicholas J. Cassissi, M.D. University of Florida Rita Castagna Assumption College Charles Cavagnaro University of Memphis Kathy D. Clark University of Idaho Kenneth S. Clarke Pennsylvania State University Priscilla M. Clarkson University of Massachusetts, Amherst Bob Colgate National Federation of State High School Associations Donald Cooper, M.D. Oklahoma State University Kip Corrington Texas A&M University, College Station Lauren Costello, M.D. Princeton University Ron Courson University of Georgia Carmen Cozza Yale University Bernie DePalma Cornell University Jerry L. Diehl National Federation of State High School Associations Larry Fitzgerald Southern Connecticut State University

Paul W. Gikas, M.D. University of Michigan Pamela Gill-Fisher University of California, Davis Gordon L. Graham Minnesota State University Mankato Gary A. Green, M.D. University of California, Los Angeles Letha Griffin, M.D. Georgia State University Eric Hamilton The College of New Jersey Kim Harmon University of Washington Richard J. Hazelton Trinity College (Connecticut) Larry Holstad Winona State University Maria J. Hutsick Boston University Nell C. Jackson Binghamton University John K. Johnston Princeton University Don Kaverman Southeast Missouri State University Janet R. Kittell California State University, Chico Fran Koenig Central Michigan University Olav B. Kollevoll Lafayette College Jerry Koloskie University of Nevada, Las Vegas Roy F. Kramer Vanderbilt University Michael Krauss, M.D. Purdue University

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Acknowledgements Carl F. Krein Central Connecticut State University Russell M. Lane, M.D. Amherst College John Lombardo, M.D. The Ohio State University Scott Lynch Pennsylvania State University William B. Manlove Jr. Delaware Valley College Arnold Mazur, M.D. Boston College Chris McGrew, M.D. University of New Mexico William D. McHenry Washington and Lee University Malcolm C. McInnis Jr. University of Tennessee, Knoxville Douglas B. McKeag, M.D. Michigan State University Kathleen M. McNally La Salle University Robin Meiggs Humboldt State University Dale P. Mildenberger Utah State University Melinda L. Millard-Stafford Georgia Institute of Technology Fred L. Miller Arizona State University Matthew Mitten Marquette University Frederick O. Mueller University of North Carolina, Chapel Hill David M. Nelson University of Delaware William E. Newell Purdue University Jeffrey Oâ&#x20AC;&#x2122;Connell University of Virginia Roderick Paige Texas Southern University Joseph V. Paterno Pennsylvania State University Marc Paul University of Nevada,â&#x20AC;&#x2C6;Reno Daniel Pepicelli St. John Fisher College

118

Frank Pettrone, M.D. George Mason University Marcus L. Plant University of Michigan Nicole Porter Shippensburg University of Pennsylvania James C. Puffer, M.D. University of California, Los Angeles Margot Putukian Princeton University Ann Quinn-Zobeck University of Northern Colorado Tracy Ray Samford University Joy L. Reighn Rowan University Frank J. Remington University of Wisconsin, Madison Rochel Rittgers Augustana College (Illinois) Darryl D. Rogers Southern Connecticut State University Yvette Rooks University of Maryland, College Park Debra Runkle University of Dubuque Richard D. Schindler National Federation of State High School Associations Kathy Schniedwind Illinois State University Brian J. Sharkey University of Montana Willie G. Shaw North Carolina Central University Jen Palancia Shipp University of North Carolina, Greensboro Gary Skrinar Boston University Bryan W. Smith, M.D. University of North Carolina, Chapel Hill Michael Storey Bridgewater State College

Grant Teaff Baylor University Carol C. Teitz, M.D. University of Washington Patricia Thomas Georgetown University Susan S. True National Federation of State High School Associations Laurie Turner University of California, San Diego Jerry Weber University of Nebraska, Lincoln Christine Wells Arizona State University Kevin M. White Tulane University Robert C. White Wayne State University (Michigan) Sue Williams University of California, Davis Charlie Wilson Olivet College G. Dennis Wilson Auburn University Mary Wisniewski University of Chicago Glenn Wong University of Massachusetts, Amherst Joseph P. Zabilski Northeastern University Connee Zotos Drew University

Appendix D

2010-11 NCAA Banned Drugs The NCAA bans the following classes of drugs: a. Stimulants; b. Anabolic Agents; c. Alcohol and Beta Blockers (banned for rifle only); d. Diuretics and Other Masking Agents; e. Street Drugs; f. Peptide Hormones and Analogues; g. Anti-Estrogens; and h. Beta-2 Agonists. Note: Any substance chemically related to these classes is also banned. The institution and the student-athlete shall be held accountable for all drugs within the banned-drug class regardless of whether they have been specifically identified.

Drugs and Procedures Subject to Restrictions: • • • • •

Blood Doping. Local Anesthetics (under some conditions). Manipulation of Urine Samples. Beta-2 Agonists permitted only by prescription and inhalation. Caffeine – if concentrations in urine exceed 15 micrograms/ml.

NCAA Nutritional/Dietary Supplements Warning: • B efore consuming any nutritional/dietary supplement product, review the product and its label with your athletics department staff! • Dietary supplements are not well regulated and may cause a positive drug test result. • Student-athletes have tested positive and lost their eligibility using dietary supplements. • Many dietary supplements are contaminated with banned drugs not listed on the label. • Any product containing a dietary supplement ingredient is taken at your own risk. Information about ingredients in medications and nutritional/dietary supplements can be obtained by contacting the Resource Exchange Center (REC) at 877/202-0769 or www. drugfreesport.com/rec (password ncaa1, ncaa2 or ncaa3).

119

Banned Drug Classes

Some Examples of NCAA Banned Substances in Each Drug Class NOTE: There is no complete list of banned drug examples! Stimulants: amphetamine (Adderall); caffeine (guarana); cocaine; ephedrine; fenfluramine (Fen); methamphetamine; methylphenidate (Ritalin); phentermine (Phen); synephrine (bitter orange); etc. Exceptions: phenylephrine and pseudoephedrine are not banned. Anabolic Agents (sometimes listed as a chemical formula, such as 3,6,17-androstenetrione): boldenone; clenbuterol; DHEA; nandrolone; stanozolol; testosterone; methasterone; androstenedione; norandrostenedione; methandienone; etiocholanolone; trenbolone; etc. Alcohol and Beta Blockers (banned for rifle only): alcohol; atenolol; metoprolol; nadolol; pindolol; propranolol; timolol; etc. Diuretics (water pills) and Other Masking Agents: bumetanide; chlorothiazide; furosemide; hydrochlorothiazide; probenecid; spironolactone (canrenone); triameterene; trichlormethiazide; etc. Street Drugs: heroin; marijuana; tetrahydrocannabinol (THC) â&#x20AC;&#x201C; no other substances are classified as NCAA street drugs. Peptide Hormones and Analogues: growth hormone (hGH); human chorionic gonadotropin (hCG); erythropoietin (EPO); etc. Anti-Estrogens: anastrozole; tamoxifen; formestane; 3,17-dioxo-etiochol-1,4,6-triene(ATD), etc. Beta-2 Agonists: bambuterol; formoterol; salbutamol; salmeterol; etc. Any substance that is chemically related to the class of banned drugs is also banned (unless otherwise noted)!

120

The NCAA salutes the more than 400,000 student-athletes participating in 23 sports at more than 1,000 member institutions

NCAA 77268-7/10

MD 11

MEMORANDUM

April 29, 2010

TO: NCAA Head Athletic Trainers. FROM: Debra Runkle, chair NCAA Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS). SUBJECT: Concussion Management Plan.

The NCAA is committed to the prevention, identification, evaluation and management of concussions. The NCAA’s latest step in the process to develop a consistent association-wide approach to concussion management has come from the NCAA Executive Committee. The Executive Committee adopted the following policy for institutions across all three divisions. “Institutions shall have a concussion management plan on file such that a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion. Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day. Medical clearance shall be determined by the team physician or their designee according to the concussion management plan. In addition, student-athletes must 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. During the review and signing process studentathletes should be presented with educational material on concussions.” The policy came from ongoing review of research data and discussions with the medical community. Determination of appropriate care and treatment of studentathletes injuries and illness are best handled through a local institutional medical model that has team physician oversight and direction. This model should focus on appropriate access to healthcare providers with the unchallengeable authority to determine management and return-to-play.

NCAA MEMORANDUM April 29, 2010 Page No. 2 _________

Institutions should be prepared to respond to immediate emergency situations (e.g., intracranial hemorrhage, cardiac arrest, heat illness, exertional sickling, respiratory distress, spinal injury, fractures) as part of their emergency care plans for each venue but also the continued evaluation and care for non-emergency yet serious conditions (e.g., concussion, sprains, strains, bleeding, fractures). With this in mind, institutions should have both a written emergency plan as well as a written concussion management plan on file. The committee reaffirms its recommendation from December 2009 that an athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulty with memory function should not be allowed to return to play during the same day of competition and expands upon it by stating a student-athlete diagnosed with a concussion should not return to activity for the remainder of that day. Student-athletes that sustain a concussion outside of their sport should be managed in the same manner as those sustained during sport activity. The student-athlete should be monitored for recurrence of symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games, working on a computer, classroom work, or taking a test. Also in December, the committeeâ&#x20AC;&#x2122;s recommendations reinforced medical policies that already are in place at many NCAA institutions while encouraging institutions to develop protocols under the direction of a physician for responding to possible concussions. To provide more guidance on protocol development, the CSMAS has approved a set of recommended best practices appropriate for the NCAA collegiate environment. The basic principles are based on the 2008 Consensus Statement on Concussion in Sport 3rd International Conference held in Zurich and the NCAA Sports Medicine Handbook with expanded language that reinforces the Executive Committeeâ&#x20AC;&#x2122;s adopted policy. As noted in the handbook guideline on concussions, neuropsychological testing has proven to be an effective tool in assessing neurocognitive changes following concussion and can serve as an important component of an institutionâ&#x20AC;&#x2122;s concussion management plan. However, neuropsychological tests should not be used as a standalone measure to diagnose the presence or absence of a concussion and should not be used in lieu of a comprehensive assessment by qualified healthcare providers. Healthcare professionals should assume a concussion when unsure and waiting for final diagnosis. When in doubt, sit the athlete out. Institutions should ensure healthcare professionals attain continuing education on concussion evaluation and management annually. Structured and documented education of student-athletes and coaches is also recommended to improve the success of the recognition and referral components of a consistent concussion management program. Educational materials on concussions can be found at www.ncaa.org/health-safety. A webinar is planned for medical staff this summer. The following recommended best practices should be considered by each institution for developing a plan to address concussion in sport.

NCAA MEMORANDUM April 29, 2010 Page No. 3 _________

Recommended Best Practices for a Concussion Management Plan for all NCAA Institutions 1.

Institutions shall require student-athletes to sign a statement in which student-athletes accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process student-athletes should be presented with educational material1 on concussions.

Institutions should have on file and annually update an emergency action plan2,3,4 for each athletics venue to respond to student-athlete catastrophic injuries and illnesses, including but not limited to concussions, heat illness, spine injury, cardiac arrest, respiratory distress (e.g. asthma), and sickle cell trait collapses. All athletics healthcare providers and coaches should review and practice the plan at least annually.

Institutions should have on file an appropriate healthcare plan5 that includes equitable access to athletics healthcare providers for each NCAA sport.

Athletics healthcare providers should be empowered to have the unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. For example, a countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should they have sole hiring or firing authority over that provider.

Institutions shall have on file a written team physician窶電irected concussion management plan2,6 that specifically outlines the roles of athletics healthcare staff (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neuropsychologist). In addition, the following components have been specifically identified for the collegiate environment: a.

Institutions should ensure coaches have acknowledged they understand the concussion management plan, their role within the plan and that they received education1 about concussions.

Athletics healthcare providers should practice within the standards as established for their professional practice (e.g., physician7, certified athletic trainer8, nurse practitioner, physician assistant, neurologist9, neuropsychologist10).

Institutions should record a baseline assessment6,10,11,12 for each student-athlete prior to the first practice in the sports of baseball, basketball, diving, equestrian, field hockey, football, gymnastics, ice hockey, lacrosse, pole vaulting, rugby, soccer, softball, water polo, and wrestling, at a minimum. The same baseline assessment tools should be used post-injury at appropriate time intervals. The baseline assessment should consider one or more of the following areas of assessment.

NCAA MEMORANDUM April 29, 2010 Page No. 4 _________

1) At a minimum, the baseline assessment should consist of the use of a symptoms checklist and standardized cognitive and balance assessments (e.g., SAC; SCAT; SCAT II6; Balance Error Scoring System (BESS); Neurocom). 2) Additionally, neuropsychological testing (e.g., computerized, standard paper and pencil) has been shown to be effective in the evaluation and management of concussion. The development and implementation of a neuropsychological testing program should be performed in consultation with a neuropsychologist. Ideally, post injury neuropsychological test data should be interpreted by a neuropsychologist. d.

When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussion.

A student-athlete diagnosed with a concussion shall be withheld from the competition or practice and not return to activity for the remainder of that day.

The student-athlete should receive serial monitoring for deterioration. Athletes should be provided with written instructions upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions.

The student-athlete should be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play should follow a medically supervised stepwise process.

Final authority for Return-to-Play13 shall reside with the team physician or the physicianâ&#x20AC;&#x2122;s designee.

Institutions should document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion.

Although sports currently have rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced.

NCAA MEMORANDUM April 29, 2010 Page No. 5 _________

Reference Documents. 1. NCAA and CDC Educational Material on Concussion in Sport. Available online at www.ncaa.org/health-safety 2. NCAA Sports Medicine Handbook. 2009-2010. 3. National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics. Journal of Athletic Training, 2002; 37(1):99–104. 4. Sideline Preparedness for the Team Physician: A Consensus Statement. 2000. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM. 5. Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics. National Athletic Trainer’s Association. 2000. Revised 2003, 2007, 2010. 6. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, 2008. Clinical Journal of Sport Medicine, 2009; 19(3):185-200. 7. Concussion (Mild Traumatic Brain Injury) and the Team Physician: A Consensus Statement. 2006. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM. 8. National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. Journal of Athletic Training, 2004; 39:280-297. 9. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology, 1997; 48:581-5. 10. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. National Academy of Neuropsychology position paper. Moser, Iverson, Echemendia, Lovell, Schatz Webbe, Ruff , Barth. Archives of Clinical Neuropsychology, 2007; 22:909–916. 11. Who should conduct and interpret the neuropsychological assessment in sports-related concussion? Echemendia RJ, Herring S, Bailes J. British Journal of Sports Medicine, 2009; 43:i32-i35. 12. Test-retest reliability of computerized concussion assessment programs. Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R Journal of Athletic Training, 2007; 42(4):509-514. 13. The Team Physician and Return-To-Play Issues: A Consensus Statement. 2002. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM.

Behind the Blue Disk NCAA Approach to Concussions What is a concussion? A concussion is a minor traumatic brain injury characterized by a rapid onset of cognitive impairment. Concussions are often difficult to detect since most don’t lead to a loss of consciousness or have other immediately recognizable symptoms. What causes a concussion? Concussions typically occur from blows to the head either from contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. What are the numbers on concussion? The NCAA is constantly seeking to protect the health and safety of its student-athletes. One way it does is by using an injury surveillance program to monitor injury trends. The data from the program show concussions represent 5 to 18 percent of the total reported injuries, depending on the sport. As with many injuries, there is reason to believe these numbers are understated since student-athletes may not necessarily report injuries for fear of losing playing time. Common signs and symptoms of concussions: Loss of consciousness Confusion Amnesia Balance Problems Headache Visual Disturbance

“Whenever you play competitive sports, there is the risk of injury. When it comes to concussion, clear return-to-play guidelines, proper coaching techniques, enforcement of existing rules and the use of properly fitted equipment can minimize the risk.” David Klossner, Director of Health and Safety

What is the NCAA doing to prevent further concussions? In addition to funding studies, the NCAA informs student-athletes, institutional staff and sport officials on current prevention and return-to-play measures. When appropriate, it recommends changes to Association playing rules to make competitions safer. Does the NCAA require neuropsychological testing? The NCAA Sports Medicine Handbook guidelines recommend a number of evaluation measures for student-athletes who have sustained a concussion, including neuropsychological testing. The NCAA does not require one specific assessment tool.

What does the NCAA recommend regarding concussion management? It is essential no student-athlete return to participation in a game, practice or other contest when symptoms persist either at rest or exertion. A student-athlete with any injury that involves unconsciousness, amnesia or persistent confusion should not be allowed to return to play the same day. What role do NCAA rules play in the prevention of concussions? NCAA rules committees oversee the playing rules of each sport and work closely with the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and other medical experts to make competitions safer. What role does the school play in the prevention and treatment of concussions? Ultimately, it is the school’s responsibility to protect the health of its student-athletes. The NCAA publishes its sports medicine handbook to provide specific guidance on the treatment and prevention of concussions. Please access Behind the Blue Disk via www.ncaa.org for the most up-to-date information. For more information, contact NCAA Public and Media Relations at 317/917-6117.

1/8/2010

CONCUSSION A fact sheet for student-athletes

What is a concussion?

A concussion is a brain injury that: • Is caused by a blow to the head or body. – From contact with another player, hitting a hard surface such as the ground, ice or floor, or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball. • Can change the way your brain normally works. • Can range from mild to severe. • Presents itself differently for each athlete. • Can occur during practice or competition in ANY sport. • Can happen even if you do not lose consciousness.

How can I prevent a concussion?

Basic steps you can take to protect yourself from concussion: • Do not initiate contact with your head or helmet. You can still get a concussion if you are wearing a helmet. • Avoid striking an opponent in the head. Undercutting, flying elbows, stepping on a head, checking an unprotected opponent, and sticks to the head all cause concussions. • Follow your athletics department’s rules for safety and the rules of the sport. • Practice good sportsmanship at all times. • Practice and perfect the skills of the sport.

What are the symptoms of a concussion?

You can’t see a concussion, but you might notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms include: • Amnesia. • Confusion. • Headache. • Loss of consciousness. • Balance problems or dizziness. • Double or fuzzy vision. • Sensitivity to light or noise. • Nausea (feeling that you might vomit). • Feeling sluggish, foggy or groggy. • Feeling unusually irritable. • Concentration or memory problems (forgetting game plays, facts, meeting times). • Slowed reaction time. Exercise or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games may cause concussion symptoms (such as headache or tiredness) to reappear or get worse.

What should I do if I think I have a concussion?

Don’t hide it. Tell your athletic trainer and coach. Never ignore a blow to the head. Also, tell your athletic trainer and coach if one of your teammates might have a concussion. Sports have injury timeouts and player substitutions so that you can get checked out. Report it. Do not return to participation in a game, practice or other activity with symptoms. The sooner you get checked out, the sooner you may be able to return to play. Get checked out. Your team physician, athletic trainer, or health care professional can tell you if you have had a concussion and when you are cleared to return to play. A concussion can affect your ability to perform everyday activities, your reaction time, balance, sleep and classroom performance. Take time to recover. If you have had a concussion, your brain needs time to heal. While your brain is still healing, you are much more likely to have a repeat concussion. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change your whole life.

It’s better to miss one game than the whole season. When in doubt, get checked out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion.

Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

CONCUSSION A fact sheet for Coaches

The Facts

• A concussion is a brain injury. • All concussions are serious. • Concussions can occur without loss of consciousness or other obvious signs. • Concussions can occur from blows to the body as well as to the head. • Concussions can occur in any sport. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. • Athletes may not report their symptoms for fear of losing playing time. • Athletes can still get a concussion even if they are wearing a helmet. • Data from the NCAA Injury Surveillance System suggests that concussions represent 5 to 18 percent of all reported injuries, depending on the sport.

What is a concussion?

A concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head. Concussions can also result from hitting a hard surface such as the ground, ice or floor, from players colliding with each other or being hit by a piece of equipment such as a bat, lacrosse stick or field hockey ball.

Recognizing a possible concussion

To help recognize a concussion, watch for the following two events among your student-athletes during both games and practices: 1. A forceful blow to the head or body that results in rapid movement of the head; -AND2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms).

Signs and Symptoms Signs Observed By Coaching Staff • Appears dazed or stunned. • Is confused about assignment or position. • Forgets plays. • Is unsure of game, score or opponent. • Moves clumsily. • Answers questions slowly. • Loses consciousness (even briefly). • Shows behavior or personality changes. • Can’t recall events before hit or fall. • Can’t recall events after hit or fall.

Symptoms Reported By Student-Athlete • Headache or “pressure” in head. • Nausea or vomiting. • Balance problems or dizziness. • Double or blurry vision. • Sensitivity to light. • Sensitivity to noise. • Feeling sluggish, hazy, foggy or groggy. • Concentration or memory problems. • Confusion. • Does not “feel right.”

PREVENTION AND PREPARATION

As a coach, you play a key role in preventing concussions and responding to them properly when they occur. Here are some steps you can take to ensure the best outcome for your student-athletes: • Educate student-athletes and coaching staff about concussion. Explain your concerns about concussion and your expectations of safe play to student-athletes, athletics staff and assistant coaches. Create an environment that supports reporting, access to proper evaluation and conservative return-to-play. – Review and practice your emergency action plan for your facility. – Know when you will have sideline medical care and when you will not, both at home and away. – Emphasize that protective equipment should fit properly, be well maintained, and be worn consistently and correctly. – Review the Concussion Fact Sheet for Student-Athletes with your team to help them recognize the signs of a concussion. – Review with your athletics staff the NCAA Sports Medicine Handbook guideline: Concussion or Mild Traumatic Brain Injury (mTBI) in the Athlete. • Insist that safety comes first. – Teach student-athletes safe-play techniques and encourage them to follow the rules of play. – Encourage student-athletes to practice good sportsmanship at all times. – Encourage student-athletes to immediately report symptoms of concussion. • Prevent long-term problems. A repeat concussion that occurs before the brain recovers from the previous one (hours, days or weeks) can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death.

IF YOU THINK YOUR STUDENT-ATHLETE HAS SUSTAINED A CONCUSSION:

IF A CONCUSSION IS SUSPECTED:

Take him/her out of play immediately and allow adequate time for evaluation by a health care professional experienced in evaluating for concussion.

1. Remove the student-athlete from play. Look for the signs and symptoms of concussion if your student-athlete has experienced a blow to the head. Do not allow the student-athlete to just “shake it off.” Each individual athlete will respond to concussions differently.

An athlete who exhibits signs, symptoms or behaviors consistent with a concussion, either at rest or during exertion, should be removed immediately from practice or competition and should not return to play until cleared by an appropriate health care professional. Sports have injury timeouts and player substitutions so that student-athletes can get checked out.

2. Ensure that the student-athlete is evaluated right away by an appropriate health care professional. Do not try to judge the severity of the injury yourself. Immediately refer the studentathlete to the appropriate athletics medical staff, such as a certified athletic trainer, team physician or health care professional experienced in concussion evaluation and management. 3. Allow the student-athlete to return to play only with permission from a health care professional with experience in evaluating for concussion. Allow athletics medical staff to rely on their clinical skills and protocols in evaluating the athlete to establish the appropriate time to return to play. A return-to-play progression should occur in an individualized, step-wise fashion with gradual increments in physical exertion and risk of contact. 4. Develop a game plan. Student-athletes should not return to play until all symptoms have resolved, both at rest and during exertion. Many times, that means they will be out for the remainder of that day. In fact, as concussion management continues to evolve with new science, the care is becoming more conservative and return-to-play time frames are getting longer. Coaches should have a game plan that accounts for this change.

It’s better they miss one game than the whole season. When in doubt, sit them out. For more information and resources, visit www.NCAA.org/health-safety and www.CDC.gov/Concussion.

Reference to any commercial entity or product or service on this page should not be construed as an endorsement by the Government of the company or its products or services.

Overview and Features of the ImPACT Test ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most-widely used, and most scientifically validated computerized concussion evaluation system. Developed in the early 1990's by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages. ImPACT Applications, Inc. was co-founded by Mark Lovell, PhD, Joseph Maroon, MD, and Michael (Micky) Collins, PhD. Given the inherent difficulties in concussion management, it is important to manage concussions on an individualized basis and to implement baseline testing and/or post-injury neurocognitive testing. This type of concussion assessment can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts. ImPACT can be administered by an athletic trainer, school nurse, athletic director, team coach, team doctor, or anyone trained to administer baseline testing. ImPACT is the most widely used computer-based testing program in the world and is implemented effectively across high school, collegiate, and professional levels of sport participation.

Test Features          

Measures player symptoms Measures verbal and visual memory, processing speed and reaction time Reaction time measured to 1/100th of second Assists clinicians and athletic trainers in making difficult return-to-play decisions Provides reliable baseline test information Produces comprehensive report of test results Results can be e-mailed or faxed for fast consultation by a neuropsychologist Automatically stores data from repeat testing Testing is administered online for individuals or groups Compatible with PC and MAC

The test battery consists of a near infinite number of alternate forms by randomly varying the stimulus array for each administration. This feature was built in to the program to minimize the "practice effects" that have limited the usefulness of more traditional neurocognitive tests. ImPACT takes approximately 20 minutes to complete. The program measures multiple aspects of cognitive functioning in athletes, including:  Attention span  Working memory  Sustained and selective attention time  Response variability  Non-verbal problem solving  Reaction time

Test Overview   

 

Section 1: Demographic Information & Health History Questionnaire Section 2: Current Symptoms and Conditions Section 3: Neuropsychological Tests (baseline testing and post-injury testing) o Module 1: Word Memory o Module 2: Design Memory o Module 3: X's and O's o Module 4: Symbol Matching o Module 5: Color Match o Module 6: Three Letter Memory Section 4: Injury Description Section 5: ImPACT Test Scores

SCAT2 Sport Concussion Assessment Tool 2

Symptom Evaluation

Name

How do you feel? You should score yourself on the following symptoms, based on how you feel now.

Sport / team

none

Date / time of injury

Date / time of assessment

Age

Gender

M n

Years of education completed

Examiner

What is the SCAT2?1 This tool represents a standardized method of evaluating injured athletes for concussion and can be used in athletes aged from 10 years and older. It supersedes the original SCAT published in 20052. This tool also enables the calculation of the Standardized Assessment of Concussion (SAC)3, 4 score and the Maddocks questions5 for sideline concussion assessment.

Instructions for using the SCAT2 The SCAT2 is designed for the use of medical and health professionals. Preseason baseline testing with the SCAT2 can be helpful for interpreting post-injury test scores. Words in Italics throughout the SCAT2 are the instructions given to the athlete by the tester. This tool may be freely copied for distribtion to individuals, teams, groups and organizations.

What is a concussion? A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of nonspecific symptoms (like those listed below) and often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following: • Symptoms (such as headache), or • Physical signs (such as unsteadiness), or • Impaired brain function (e.g. confusion) or • Abnormal behaviour. Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle.

mild

moderate

severe

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

Trouble falling asleep (if applicable)

More emotional

Irritability

Sadness

Nervous or Anxious

Total number of symptoms (Maximum possible 22) Symptom severity score (Add all scores in table, maximum possible: 22 x 6 = 132)

Do the symptoms get worse with physical activity? Do the symptoms get worse with mental activity?

Y Y

N N

Overall rating If you know the athlete well prior to the injury, how different is the athlete acting compared to his / her usual self? Please circle one response. no different

SCAT2 Sport Concussion Assesment Tool 2 | Page 1

very different

unsure

Cognitive & Physical Evaluation 1

Symptom score (from page 1)

22 minus number of symptoms

of 22

Cognitive assessment Standardized Assessment of Concussion (SAC) Orientation (1 point for each correct answer)

Physical signs score Was there loss of consciousness or unresponsiveness? If yes, how long? minutes Was there a balance problem / unsteadiness?

of 2

Physical signs score (1 point for each negative response)

Glasgow coma scale (GCS) Best eye response (E) No eye opening Eye opening in response to pain Eye opening to speech Eyes opening spontaneously

1 2 3 4

Best verbal response (V) No verbal response Incomprehensible sounds Inappropriate words Confused Oriented

1 2 3 4 5

Best motor response (M) No motor response Extension to pain Abnormal flexion to pain Flexion / Withdrawal to pain Localizes to pain Obeys commands

1 2 3 4 5 6

Glasgow Coma score (E + V + M)

of 5

Trials 2 & 3: “I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.“ Complete all 3 trials regardless of score on trial 1 & 2. Read the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested. List

elbow apple carpet saddle bubble Total

of 15

Maddocks score

1 1 1 1 1 of 5

Maddocks score is validated for sideline diagnosis of concussion only and is not included in SCAT 2 summary score for serial testing.

This tool has been developed by a group of international experts at the 3rd International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2008. The full details of the conference outcomes and the authors of the tool are published in British Journal of Sports Medicine, 2009, volume 43, supplement 1. The outcome paper will also be simultaneously co-published in the May 2009 issues of Clinical Journal of Sports Medicine, Physical Medicine & Rehabilitation, Journal of Athletic Training, Journal of Clinical Neuroscience, Journal of Science & Medicine in Sport, Neurosurgery, Scandinavian Journal of Science & Medicine in Sport and the Journal of Clinical Sports Medicine.

cCrory P et al. Summary and agreement statement of the 2 International M Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine. 2005; 39: 196-204 nd

Trial 3

0 0 0 0 0

1 1 1 1 1

Alternative word list

candle paper sugar sandwich wagon

baby finger monkey penny perfume blanket sunset lemon iron insect of 15

Concentration Digits Backward: “I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.”

Modified Maddocks questions (1 point for each correct answer) 0 0 0 0 0

Trial 2

If correct, go to next string length. If incorrect, read trial 2. One point possible for each string length. Stop after incorrect on both trials. The digits should be read at the rate of one per second.

“I am going to ask you a few questions, please listen carefully and give your best effort.”

At what venue are we at today? Which half is it now? Who scored last in this match? What team did you play last week / game? Did your team win the last game?

Trial 1

Immediate memory score

Sideline Assessment – Maddocks Score

Orientation score

1 1 1 1 1

Immediate memory “I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.”

GCS should be recorded for all athletes in case of subsequent deterioration.

0 0 0 0 0

What month is it? What is the date today? What is the day of the week? What year is it? What time is it right now? (within 1 hour)

Alternative digit lists

4-9-3 3-8-1-4 6-2-9-7-1 7-1-8-4-6-2

0 0 0 0

1 1 1 1

6-2-9 3-2-7-9 1-5-2-8-6 5-3-9-1-4-8

5-2-6 1-7-9-5 3-8-5-2-7 8-3-1-9-6-4

4-1-5 4-9-6-8 6-1-8-4-3 7-2-4-8-5-6

Months in Reverse Order: “Now tell me the months of the year in reverse order. Start with the last month and go backward. So you’ll say December, November ... Go ahead” 1 pt. for entire sequence correct

Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan Concentration score

1 of 5

cCrea M. Standardized mental status testing of acute concussion. Clinical M Journal of Sports Medicine. 2001; 11: 176-181

cCrea M, Randolph C, Kelly J. Standardized Assessment of Concussion: M Manual for administration, scoring and interpretation. Waukesha, Wisconsin, USA.

addocks, DL; Dicker, GD; Saling, MM. The assessment of orientation M following concussion in athletes. Clin J Sport Med. 1995;5(1):32–3

uskiewicz KM. Assessment of postural stability following sport-related G concussion. Current Sports Medicine Reports. 2003; 2: 24-30

SCAT2 Sport Concussion Assesment Tool 2 | Page 2

Balance examination This balance testing is based on a modified version of the Balance Error Scoring System (BESS)6. A stopwatch or watch with a second hand is required for this testing.

Coordination examination Upper limb coordination Finger-to-nose (FTN) task: “I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended). When I give a start signal, I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose as quickly and as accurately as possible.”

Balance testing “I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“ (a) Double leg stance: “The first stance is standing with your feet together with your hands on your hips and with your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“

Which arm was tested:

(b) Single leg stance: “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now stand on your non-dominant foot. The dominant leg should be held in approximately 30 degrees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.“

Coordination score

(c) Tandem stance: “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed across both feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.” Balance testing – types of errors 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec

Scoring:

Left

Right

5 correct repetitions in < 4 seconds = 1

Note for testers: Athletes fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as 0.

of 1

Cognitive assessment Standardized Assessment of Concussion (SAC) Delayed recall “Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.“ Circle each word correctly recalled. Total score equals number of words recalled. List

elbow apple carpet saddle bubble

Alternative word list

candle paper sugar sandwich wagon

Delayed recall score

baby monkey perfume sunset iron

finger penny blanket lemon insect

of 5

Overall score Test domain

Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the athlete. The examiner will begin counting errors only after the individual has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the three 20-second tests. The maximum total number of errors for any single condition is 10. If a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition. Which foot was tested: Left Right (i.e. which is the non-dominant foot) Condition

Total errors

Double Leg Stance (feet together) Single leg stance (non-dominant foot) Tandem stance (non-dominant foot at back)

of 10 of 10 of 10

Balance examination score (30 minus total errors)

of 30

Score

Symptom score Physical signs score Glasgow Coma score (E + V + M) Balance examination score Coordination score Subtotal

of 22 of 2 of 15 of 30 of 1 of 70

Orientation score Immediate memory score Concentration score Delayed recall score SAC subtotal

of 5 of 5 of 15 of 5 of 30

SCAT2 total

of 100

Maddocks Score

of 5

Definitive normative data for a SCAT2 “cut-off” score is not available at this time and will be developed in prospective studies. Embedded within the SCAT2 is the SAC score that can be utilized separately in concussion management. The scoring system also takes on particular clinical significance during serial assessment where it can be used to document either a decline or an improvement in neurological functioning.

Scoring data from the SCAT2 or SAC should not be used as a stand alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion.

SCAT2 Sport Concussion Assesment Tool 2 | Page 3

Athlete Information Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation.

Signs to watch for

Return to play

Problems could arise over the first 24-48 hours. You should not be left alone and must go to a hospital at once if you: • Have a headache that gets worse • Are very drowsy or can’t be awakened (woken up) • Can’t recognize people or places • Have repeated vomiting • Behave unusually or seem confused; are very irritable • Have seizures (arms and legs jerk uncontrollably) • Have weak or numb arms or legs • Are unsteady on your feet; have slurred speech

Athletes should not be returned to play the same day of injury. When returning athletes to play, they should follow a stepwise symptom-limited program, with stages of progression. For example: 1. rest until asymptomatic (physical and mental rest) 2. light aerobic exercise (e.g. stationary cycle) 3. sport-specific exercise 4. non-contact training drills (start light resistance training) 5. full contact training after medical clearance 6. return to competition (game play) There should be approximately 24 hours (or longer) for each stage and the athlete should return to stage 1 if symptoms recur. Resistance training should only be added in the later stages. Medical clearance should be given before return to play.

Remember, it is better to be safe. Consult your doctor after a suspected concussion.

Tool

Test domain

Time

Score

Date tested Days post injury Symptom score Physical signs score Glasgow Coma score (E + V + M) SCAT2 Balance examination score Coordination score Orientation score Immediate memory score SAC Concentration score Delayed recall score SAC Score Total

SCAT2

Symptom severity score (max possible 132) Return to play

n Y

n N

n Y

n N

n Y

n N

n Y

n N

Additional comments

Concussion injury advice

(To be given to concussed athlete)

This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. It is expected that recovery will be rapid, but the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to this timeframe. If you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please telephone the clinic or the nearest hospital emergency department immediately.

Patient’s name Date / time of injury Date / time of medical review Treating physician

Other important points: • • • •

Rest and avoid strenuous activity for at least 24 hours No alcohol No sleeping tablets Use paracetamol or codeine for headache. Do not use aspirin or anti-inflammatory medication • Do not drive until medically cleared • Do not train or play sport until medically cleared

Clinic phone number

SCAT2 Sport Concussion Assesment Tool 2 | Page 4

Contact details or stamp

HIS-S: Symptom Checklist Please circle the appropriate answer to each question indicating how you feel at this very moment. Is your vision blurry? Are you feeling nervous? Are you feeling "slowed down"? Do you have a headache? Are you feeling nauseous? Are you feeling drowsy? Are you sensitive to noise? Do you feel sad? Do you feel like you are "in a fog"? Are you feeling irritable? Are you having difficulty balancing? Are you feeling fatigued? Do you feel numbness anywhere in your body? Are you having difficulty concentrating? Are your eyes sensitive to light? Have you vomited recently? Are you feeling depressed? Are you feeling any"pressure in your head"? Are you feeling confused? Are you having difficulty remembering? Are you feeling any tingling sensations? Are you feeling dizzy?

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Claude Smith Baseball Field The following action plan should be applied during all physical activities at this facility. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home matches. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Emergency Equipment: supplies (trauma kit, splint kit, spine board, crutches) are maintained in the clubhouse. AED location is determined by the Sports Medicine Staff, and will be on site for all competitions. Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police at 478-301-2911 or 478-301-2970 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS TO CLAUDE SMITH FIELD: From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Turn Right onto Stadium Drive (West Entrance to Mercer University campus). Follow Stadium drive, and turn Right onto University Center Drive. A designated individual will be within sight on the sidewalk corner of the baseball stadium to direct EMS to the specific location of the injured athlete.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Sikes Softball Field The following action plan should be applied during all physical activities at this facility. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home matches. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Emergency Equipment: supplies (trauma kit, splint kit, spine board, crutches) are maintained in the home team dug out. AED location is determined by the Sports Medicine Staff, and will be on site for all competitions. Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police at 478-301-2911 or 478-301-2970 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS TO SIKES SOFTBALL FIELD: From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Turn Right onto College Street (East Entrance to Mercer University campus). Take Left at stop sign (Prince Street). This lead EMS to the third base side of the softball field. A designated individual will be within sight by the softball field to direct EMS to the exact location of the injury.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Bear Soccer and Lacrosse Field The following action plan should be applied during all physical activities at this facility. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home matches. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Emergency Equipment: supplies (trauma kit, splint kit, spine board) are maintained on the sideline. AED location is determined by the Sports Medicine Staff, and will be on site for all competitions. Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police at 478-301-2911 or 478-301-2970 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS TO BEAR SOCCER FIELD: From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Turn Right onto College Street (East Entrance to Mercer University campus). Take Right at stop sign (Prince Street). This lead EMS to the front gate entrance of Bear Field. A designated individual will be within sight by the soccer field to direct EMS to the exact location of the injury.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Soccer and Lacrosse Practice Fields The following action plan should be applied during all physical activities at this facility. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home matches. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Emergency Equipment: supplies (trauma kit, splint kit, spine board) are maintained on the sideline. AED location is determined by the Sports Medicine Staff, and will be on site for all competitions. Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police at 478-301-2911 or 478-301-2970 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS TO PRACTICE FIELDS: From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Take a Right into the parking lot between the practice fields. A designated individual will be in the parking lot within sight to direct EMS to the exact location of the injury.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

University Center The following action plan should be applied during all physical activities at this facility. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home matches. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Emergency Equipment: supplies (trauma kit, splint kit, spine board) are maintained on the sideline. AED location is determined by the Sports Medicine Staff, and will be on site for all competitions. Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police at 478-301-2911 or 478-301-2970 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS TO UNIVERSITY CENTER From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Turn Right onto Stadium Drive (West Entrance to Mercer University campus). Follow Stadium drive, and turn Right onto University Center Drive. Take the first Right, immediately after Claude Smith Baseball Field. Then take the First Left into the University Center Parking lot. A designated person will be within sight in the parking lot to direct EMS into the building.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Rifle The following action plan should be applied during all physical activities at these facilities. Emergency Personnel: If possible the certified athletic trainer will delegate the roles of the other personnel. If the certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call Mercer Police (if on campus) at 478-301-2911 or 478-301-2970 b. Call 911 (if off campus) c. Provide name and position d. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 7. DIRECTIONS TO UNIVERSITY CENTER: CENTER: From MCCG, head southeast on Hemlock Street. Right onto 1st Street; 1st Street turns into Telfair. Take a right onto Little Richard Penniman Blvd. Turn Right onto Stadium Drive (West Entrance to Mercer University campus). Follow Stadium drive, and turn Right onto University Center Drive. Take the first Right, immediately after Claude Smith Baseball Field. Then take the First Left into the University Center Parking lot. A designated person will be within sight in the parking lot to direct EMS into the building. 8. DIRECTIONS TO EAGLE GUN RANGE: Located on 109 Woodfield Dr., start going Northwest on Coleman Ave towards Montpelier Ave., Coleman becomes Montpelier Ave., Montpelier then becomes Columbus Rd., turn slight RIGHT onto GA-74W. Woodfield Dr. is located on the right of GA-74W. A designated individual will be within sight to direct EMS to the exact location of the injury.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Golf The following action plan should be applied during all practices or competitions. Emergency Personnel: If possible the certified athletic trainer will delegate the roles of the other personnel. If the certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call 911 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to â&#x20AC;&#x153;flag downâ&#x20AC;? and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS: Due to different locations for events, certified athletic trainer, head coach, assistant coach, or event staff should establish the directions for EMS before the athletic event begins.

MERCER SPORTS MEDICINE EMERGENCY ACTION PLAN

Cross Country The following action plan should be applied during all practices, races, or meets. Emergency Personnel: If possible there should be two Mercer University Certified Athletic Trainers present at all home, Mercer University sponsored events. This secondary athletic trainer should be ready and available during competition in the event of an injury or medical emergency. The primary athletic trainer will delegate responsibilities and roles of other personnel. If a certified athletic trainer is unavailable the head coach, assistant coach, or event staff will delegate the responsibilities. Emergency Communication: Before any event or practice the athletic trainer, head coach, assistant coach or event staff should make sure that cellular phones are operational at the event site. If a cellular phone is not available then the nearest hard line should be established and notified to the appropriate personnel. Accessibility of the hard line should be established prior to the start of competition or practice.

Roles of First responders: 1. Immediate care of the injured athlete and assessment of the situation. 2. A designated individual will retrieve the emergency equipment. 3. A designated individual will activate the emergency medical service (EMS). a. Call 911 b. Provide name and position c. Provide the following information i. Telephone number; number of individuals injured; condition of injured; severity of injury; first aid treatment; any other information required. 4. A designated person will stand in clear sight of EMS, outside of venue to “flag down” and direct EMS to the scene (sidewalk corner, outside the stands) 5. A designated individual will provide crowd control to limit the scene to the first responders and first aid providers and move bystanders away from the scene. 6. DIRECTIONS: Due to different locations for events, certified athletic trainer, head coach, assistant coach, team member, or event staff should establish the directions for EMS before the athletic event begins.

Mercer University Sports Medicine Health & Welfare Acknowledgement Name:_____________________________ Sport:_________________________ HIPAA Notice I acknowledge receipt of Mercer University’s Notice of Privacy Practices and have been given an opportunity to ask questions regarding this document. I understand that this is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I also understand that this notice describes how a student-athlete’s health information may be used and disclosed, as well as how I may be informed of pertinent information, if necessary. _________________________________

_______________

Signature

Date

Sickle Cell Notice I acknowledge that Mercer University Sports Medicine has provided me with information regarding sickle cell disease/trait and that this disorder may adversely affect persons involved in physical exertion and/or exercise. I have also been informed of the NCAA’s mandate that all student- athletes be given an opportunity to be screened for the sickle cell trait in an attempt to avoid future health problems, sickness, or death. I therefore acknowledge that the sports medicine staff (athletic trainers and physicians) will act in the best interest of those athletes that may be adversely affected by sickle cell trait and any related issues. _________________________________

_______________

Signature

Date

Emergency Action Plan Notice I have reviewed and had opportunities to ask questions regarding the emergency action plan (EAP) pertaining to my sport. I understand my role within the EAP and the duties that I may be responsible for in the event of an emergency. I understand that some injuries may be regarded as emergent situations and possibly life threatening. Therefore, I acknowledge that the sports medicine staff will make informed decisions with the student-athlete’s best interest in mind and act accordingly. In the event that the EAP is activated, I will perform my duties under the direction of the sports medicine staff. _________________________________

_______________

Signature

Date

Injury Management and Return to Play Notice In accordance with the NCAA “Best Practices “memorandum dated April 29, 2010, and the related education, training, and experience of the Sports Medicine staff; I acknowledge the right of the medical staff to make decisions in the best interest of the student-athlete’s health. In accordance with this policy, I acknowledge that the sports medicine staff (athletic trainers and physicians) is empowered to have unchallengeable authority to determine the management and return to play of any ill or injured student-athlete. _________________________________

_______________

Signature

Date

Sport Related Concussion Notice I have read the NCAA “Best Practices “memorandum from April 29, 2010 regarding sport related concussion and I have been given education on concussions as well as an opportunity to ask questions regarding these policies. I understand that any student-athlete displaying signs or symptoms consistent with a concussion will be removed from competition or practice and evaluated by a healthcare provider (athletic trainer and physician). In the event that a student-athlete is assessed with a concussion, he/she will be removed from competition or practice for the remainder of that day and routinely monitored. The concussed athlete must be evaluated by the team physician and may only be returned to play once asymptomatic and all post-exertion assessments are within normal baseline limits. Understanding this policy, I acknowledge that all return to play decisions following an injury or illness will reside solely with the sports medicine staff. Therefore, I relinquish any related decisions unto the sports medicine staff and all associated members. _________________________________

_______________

Signature

Date

Sickle Cell Trait Notification (Coach) Athlete’s name: _________________________________________ Team: ___________________________ Coaches name: __________________________________________ Date: _____ / _____ / _____ Introduction: Sickle Cell trait is the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. During periods of intense exercise the sickle cell trait can change the shape of the red blood cells from round to quarter-moon. When this occurs, these sickled red blood cells can accumulate in the bloodstream. The accumulation of sickled red blood cells can cause ischemic rhabdomyolsis, the rapid breakdown of muscle cells possibly causing death if not treated. Sickling can occur in 2-3 minutes of intense all –out exercise. Heat, dehydration, altitude, asthma, and other medical conditions may increase the risk. Telltale features of Sickling Collapse: ‐ Sickling collapse has been mistaken for cardiac collapse or heat collapse. But unlike sickling collapse, cardiac collapse tends to be “instantaneous” has no “cramping” with it, and the athlete (with Ventricular fibrillation) who hits the ground no longer talks. Unlike heat collapse, sickling collapse often occurs with-in the first half hour on field, as during wind sprints. (NATA Consensus) o Sickling does not have muscle twinges as compared to cramps; o Heat cramping pain is more severe then sickling; o Heat cramps lock up the athlete, sickling players slump to the ground in muscle weakness; o Heat crampers yell in pain with muscle contractions, sicklers lie fairly still, not yelling with normal tension in the muscles; o Sickling players caught early and treated can recover and do recover faster than athletes with dehydration and muscle cramping. Precautions and Treatment: ‐ Build up in training slowly with paced progressions, allow for longer rest and recovery periods. Athletes should be involved in year round and preseason strength and conditioning to enhance preparedness of athletes. ‐ Athletes with sickle cell trait should be excluded from participation in performance test such as mile runs, serial sprints, ect. ‐ Cessation of activity with onset of systems (muscle “cramping”, pain, swelling, weakness, tenderness; inability to “catch breath”, fatigue. The athletic trainer will have the ability to pull a sickle cell trait athlete out of activity if needed. ‐ Allow sickle cell trait athletes to set their pace. ‐ Athletes with sickle cell trait that perform repetitive high speed sprints and/or interval training that induces high levels of lactic acid should be allowed extended recovery between repetitions. ‐ Allow athletes to seek evaluation once signs and symptoms arise. These athletes also should not be harassed for sitting out. ‐ Encourage proper hydration. ‐ Asthma, heat illness, and altitude can increase the likelihood of sickling. ‐ Sickle cell trait athletes should not participate when they are ill. ‐ Educate the student-athlete about the signs and symptoms and encourage them to report these symptoms. ‐ Coach should contact ATC or EMS if sickling is suspected. 

By signing below I am stating that I have been notified of my student-athletes positive sickle cell trait test by Mercer University Sports Medicine, that I have received education on sickle cell trait, and that I have also been instructed on the proper precautions and treatment of sickle cell trait. Mercer University Sports Medicine has also answered any questions that I may have had pertaining to my athlete’s sickle cell trait.

Coach’s Signature: ____________________________________________________ Date: _____ / _____ / _____

Director of Sports Medicine signature: _____________________________________ Date: _____ / _____ / _____

Scope of Practice for Athletic Trainers at Mercer University 1.

Each licensed athletic trainer is required to practice under this written protocol established between the athletic trainer and a supervising licensed physician which contains the following a. The supervising physician’s name, license number and curriculum vitae b. The athletic trainer’s name, license number, and curriculum vitae c. The supervising physician will be contacted through a weekly injury update, which will be faxed to the physician’s private secretary/nurse or e-mailed directly to the physician. In the event that an athlete sustains an injury which is deemed to be significant and requiring additional referral, the supervising physician will be informed as quickly as possible, either by a direct phone conversation with the attending physician or his/her nurse or in person. d. The patient population to be treated will consist of students, athletes, and staff members of Mercer University. e. The assessment methods of patient status and treatment are outlined in Mercer University’s Sport’s Medicine Policy and Procedure Manual under the heading of “Preparticipation Physical Examination” and “Injury Evaluation and Referral.”

Prior to commencement of practice, each athletic trainer and the supervising physician shall develop a protocol in accordance with the above guidelines and shall review said protocol prior to the license renewal date for the athletic trainer.

A licensed athletic trainer shall apply the following principles, methods and procedures within the scope of the athletics trainer’s practice. a. Injury prevention b. Injury recognition, evaluation, and assessment c. First Aid and immediate care d. Emergency care e. Injury management, treatment and disposition f. Rehabilitation through the use of safe and appropriate physical rehabilitation practices, including those techniques and procedures following injury and recovery that restore and maintain normal function status g. Conditioning h. Performance of tests and measurements to prevent, evaluate and monitor acute and chronic injuries i. Selection and fitting of preventative and supportive devices, temporary splinting and bracing, protective equipment, strapping, and other immobilization devices and techniques to protect an injured structure, facilitate ambulation, and restore normal function j. Organization and administration of facilities within the scope of the profession k. Administration of over the counter medication and administration of prescription medication (aerosol inhalers, epinephrine auto-injectors) with a written prescription l. Education, counseling, and other advisory services for the purpose of reducing the incidence and severity of physical disability, movement dysfunction, bodily malfunction, pain, and psychological stress. m. Education and counseling to the public regarding the care and prevention of injury within the scope of the profession

For treatment and rehabilitation of muscle skeletal injuries the athletic trainer may administer the following a. Therapeutic exercise b. Massage c. Mechanical devices d. Cryo-therapy (ice, cold packs, cold water immersion, spray coolants) e. Thermo-therapy (moist/dry hot packs, heating pads, paraffin bath, topical analgesics) f. Hydro-therapy/Aquatic-therapy (whirlpool, standard pool) g. Photo-therapy (infrared, ultraviolet) h. Electro-therapy (electric stimulation, TENS, diathermy) i. Phono-therapy (ultrasound) j. Administer over the counter medications in a manner consistent with package labeling and /or instruction from a physician. k. The athletic trainer may apply topical prescription medication under the direction of a physician l. Reduction of dislocations i. Phalangeal ii. Patellofemoral iii. Recurrent dislocations iv. Dislocations which are deemed medical emergencies

This Scope of Practice will serve as a set of â&#x20AC;&#x153;Standing Ordersâ&#x20AC;? which allow Mercer University Sports Medicine and the athletic trainers employed within to perform the duties outlined in this document. All activities and procedures contained within this document are performed with the consent and direction of the supervising physician.

Reviewed and approved: __________________________ Warren Hutchings, MD

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__________________________ Tim Stapleton, MD

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__________________________ Robert Murphy, ATC

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__________________________ , ATC

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__________________________ Shawn Wolf, ATC

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__________________________ Laura Nelsen, ATC

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__________________________ Hannah Smith, ATC

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__________________________ Erik Tyler Fredlund, ATC

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__________________________ Jesse Kolodziejski, ATC

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__________________________ Sean Robb, ATC

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2010-2011 Mercer Sport Medicine Assignments High Risk Sports

Assignment

Pre-season assistant

Supervision

Women’s Soccer Men’s Soccer Volleyball Women’s Basketball Men’s Basketball Lacrosse Softball Baseball

Jesse Kolodziejski Sean Robb Hannah Smith Shawn Wolf Rob Murphy Tyler Fredlund Shawn Wolf Laura Nelsen

Laura Nelsen Shawn Wolf Tyler Fredlund

Rob Murphy

Rob Murphy Rob Murphy

Low Risk Sports Tennis Cross Country Golf (women’s) Golf (men’s) Rifle

Hannah Smith Laura Nelsen Sean Robb Jesse Kolodziejski Tyler Fredlund

Club Sports Cheerleading

Shawn Wolf

Coverage Priority High risk sports home events in-season High risk sports away events in-season Low risk sports home event in-season High risk sports practice in-season Office Hours High risk sports off season Club/Recreation sports home event Club/Recreation sports practice in season Low risk sports away event in-season Low risk sports practice in-season Low risk sports off season

Rob Murphy Rob Murphy