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University of Georgia Sports Medicine
Concussion Management Policies & Procedures
Revised June 11, 2015
In order to establish continuity of care, ensure compliance with these policies and procedures, and ensure continuous quality
improvement (CQI) we have established the Concussion Management Checklist/CQI form (Appendix 1). This form will be reviewed
annually with all sports medicine staff at the beginning of the school year. The Concussion Management Checklist will be used as a
template to ensure all policies and procedures are followed properly and that the student-athlete receives the highest level of care.
Pre-Season Education
§ UGAA will provide NCAA concussion fact sheets (Appendix 2) or other applicable materials annually to student-athletes,
coaches, team physicians, athletic trainers, and directors of athletics. Each party will provide a signed acknowledgement of
having read and understood the concussion material (Appendix 3).
§ UGAA will require student-athletes to sign a statement in which student-athletes accept the responsibility for reporting their
injuries and illnesses to the sports medicine staff, including signs and symptoms of concussions.
Pre-Participation Assessment:
§ UGAA will require that each student-athlete has received a pre-participation baseline concussion assessment which addresses
brain injury and concussion history, symptom evaluation, cognitive assessment, and balance evaluation. Each student-athlete
will receive a new baseline concussion assessment annually. The team physician will determine pre-participation clearance
and/or the need for additional consultation or testing.
§ UGAA shall record a baseline assessment6,10,11,12 for each incoming student-athlete (first-years & transfers) in all
sports. Baseline testing should be repeated annually.
§ The same baseline assessment tools should be used post-injury. The baseline assessment should consist of the use
of: 1) symptoms checklist (Appendix 4), 2) standardized balance assessment (BESS &/or Neurocom), 3)
neuropsychological testing (CNS Vital Signs &/or ImPACT), and 4) a clinical history, at a minimum. Other
measures, such as a brief visual exam (King-Devick) and a mental status exam (Standard Assessment of Concussion
- SAC) may also be administered during baseline testing at the sports medicine staff’s discretion. In the event that an
athlete does not have baseline scores, age- and gender-matched normative scores will be used for comparison to
post-injury scores.
§ Note: The neuropsychological testing program should be performed in consultation with a
neuropsychologist. Post injury neuropsychological test data will be interpreted by a neuropsychologist
prior to return to play. Neuropsychological testing has proven to be an effective tool in assessing
neurocognitive changes following concussion and can serve as an important component of an institution’s
concussion management plan. However, neuropsychological tests should not be used as a standalone
measure to diagnose the presence or absence of a concussion as UGAA uses a comprehensive assessment
by its sports medicine staff. The ImPACT neuropsychological test battery has moderate to good sensitivity
and specificity13,14,15, but poor to good reliability12,16,17. Despite the clinical limitations of the ImPACT test
battery, the test battery remains within the standard of care. The UGAA sports medicine team will continue
to review and conduct research on other computerized neuropsychological test batteries and will adjust
protocols if other products become available that have acceptable reliability. Likewise, clinical limitations
of ImPACT will be taken into consideration when interpreting all baseline and post-injury scores.
Recognition and Diagnosis of Concussion:
§ Any student-athlete with signs/symptoms/behaviors consistent with concussion must be removed from practice or
competition. The student-athlete must be evaluated by a certified athletic trainer or team physician with concussion
experience and must be removed from practice/play for that calendar day if concussion is confirmed.
§ If removed by a coaching staff member, the coach will refer the student-athlete for evaluation by a member of the sports
medicine staff. During competitions, on the field of play injuries will be under the purview of the official and playing rules
of the sport. UGAA staff will follow such rules and attend to medical situations as they arise. Visiting sport team members
evaluated by UGAA sports medicine staff will be managed in the same manner as UGAA student-athletes.
§ Within 24 hours of concussion, the supervising athletic trainer will notify the Director of Sports Medicine and Head Team
Physician, and concussion Research Laboratory Director who will review the concussion policies and procedures.
Initial Suspected Concussion Evaluation:
§ Assessment of concussion will be completed by the medical staff (athletic trainer, physician assistant and/or physician: if
physician not immediately available)
§
If a concussion is suspected, the initial concussion evaluation will include a symptom assessment (Appendix 4), a physical
and neurological exam, a cognitive assessment (SAC), a balance exam (BESS), and clinical assessment for cervical spine
trauma, skull fracture and intracranial bleed (See Appendix 5 for within 6 hour assessment packet). § The student-athlete will receive serial monitoring for deterioration. Athletes will be provided with written home instructions
(Appendix 6) that they will sign upon discharge; with a roommate, guardian, or someone that can follow the
instructions. The sports medicine staff will maintain close communication with the student-athlete following the concussion.
§ A student-athlete diagnosed with a concussion will be withheld from the competition or practice and not return to activity for
the remainder of that day. Student-athletes that sustain a concussion outside of their sport will be managed in the same
manner as those sustained during sport activity.
Post-Concussion Management:
§ Athlete should be referred to physician for evaluation within 24 hours of injury if possible if not emergent; if emergent,
athlete should be transported to the closest emergency department § UGAA will utilize an emergency action plan for head injuries, including transportation for further medical care, for any of
the following:
§ Glasgow Coma Scale < 13
§ Prolonged loss of consciousness
§ Focal neurological deficit suggesting intracranial trauma
§ Repetitive emesis
§ Persistently diminished/worsening mental status or other neurological signs/symptoms
§ Spine injury
§ Oral and written care to both the student-athlete and another responsible adult will be documented (may be parent/guardian or
roommate)
§ UGAA will utilize the post-concussion management plan described below. Sports medicine staff members will track
progression using the Concussion Management Checklist (Appendix 1).
§ 24-48 Hours Post-Injury: Athlete repeats symptom checklist, balance exam, and neuropsychological exam at a
minimum (unless directed otherwise by physician and/or neuropsychologist).
§ Daily Concussion Management While Symptomatic: The student-athlete will be monitored for recurrence of
symptoms both from physical exertion and also mental exertion, such as reading, phone texting, computer games,
watching film, athletic meetings, working on a computer, classroom work, or taking a test. Athlete held from all
physical activity; re-assess athlete daily by medical staff; administer symptom checklist daily until completely
asymptomatic; notify academic advisor (consideration of academic modifications/restrictions) (Appendix 7)
§ Athlete Asymptomatic: Athlete repeats symptom checklist, balance exam, and neuropsychological exam, at a
minimum (unless directed otherwise by physician and/or neuropsychologist). Scores will be compared to both
baseline and normative values.
• Test Results Return to Acceptable Clinical Ranges: Perform exertional testing (Appendix 8);
re-evaluation by physician for return to play decision
• Test Results NOT Returned to Acceptable Clinical Ranges: When medically cleared by
physician, repeat test battery; consider neuropsych consult with more detailed test battery
§ After Exertional Testing - Before Return to Play: Athlete repeats symptom checklist, balance exam, and
neuropsychological exam, at a minimum (unless directed otherwise by physician and/or neuropsychologist).
• Test Results Remain at Acceptable Clinical Ranges: Physician determines return to play
decision
• Test Results NOT Remain at Acceptable Clinical Ranges: When medically cleared by
physician, repeat test battery; consider neuropsych consult with more detailed test battery
§ Cases of Prolonged Recovery: Evaluation by a physician for a student-athlete with prolonged recovery (typically
considered a recovery lasting > 4 weeks) in order to consider additional diagnosis (i.e. post-concussion syndrome,
sleep dysfunction, migraine or other headache disorders, mood disorders such as anxiety and depression, ocular or
vestibular dysfunction, etc...) and best management options. Student-athletes that experience prolonged recoveries
following concussion may be allowed to complete light, low-risk physical and cognitive activities that do not worsen
symptoms at the discretion of the team physician.
§ 6 Month Follow-Up: If feasible, obtain a symptom checklist, balance exam, neuropsychological exam at a
minimum (unless directed otherwise by physician and/or neuropsychologist).
§ UGAA will 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 shall review
and practice the plan annually. These sessions will be conducted prior to the start of the sport season. The UGAA sports
medicine department and the compliance office will maintain a list of staff that have completed the requirement on file.
Return to Learn:
§ Academic advisors and professors will be notified of student-athlete’s concussion (Appendix 7), with permission for release
of information from the student-athlete. If necessary, appropriate academic accommodations will be made to help the studentathlete strike an optimum balance between rest and continued academic progress during recovery.18
§ UGAA will utilize a return-to-learn management plan that specifies:
§ The sports medicine staff, in conjunction with Athlete Academic Services, will navigate return-to-learn with the
student-athlete.
§ A multi-disciplinary team, including, but not be limited to: team physician, athletic trainer, psychologist/counselor,
neuropsychologist consultant, faculty athletic representative, academic counselor, course instructor(s), college
administrators, office of disability services representatives, and coaches will navigate more complex cases of
prolonged return-to-learn.
§ Academic accommodations will be in line with the Americans with Disabilities Act Amendments Act (ADAAA)
§ Student-athletes will not participate in classroom activity on same day as concussion.
§ Each student-athlete will receive an individualized initial plan based on their clinical presentation that includes
directions regarding:
o Remaining at home/dorm if student-athlete cannot tolerate light cognitive activity.
o Gradual return to classroom/studying as tolerated.
§ Student-athletes will be re-evaluated by their team physician if concussion symptoms worsen with academic
challenges.
§ Modification of schedule/academic accommodations may be made for student-athletes for up to two weeks, as
indicated, with help from specific academic advisor, under the direction of the senior associate athletic director of
academic services.
§ Student-athletes will be re-evaluated by their team physician and members of the multi-disciplinary team, as
appropriate if symptoms persist longer than two weeks following injury.
§ Campus resources such as UGA’s Disability Resource Center and the associate dean of student affairs will be
utilized for cases that cannot be managed through schedule modification/academic accommodations.
Return to Play:
§ When medically cleared by physician, repeat exertional testing; re-evaluation by physician for return to play decision
§ Final determination of return-to-play is from the team physician or medically qualified physician designee.
§ Each student-athlete with concussion must undergo a supervised stepwise progression management plan by a health care
provider with expertise in concussion (Appendix 8)
§
Student-athletes will review and sign the Concussion Return to Athletic Activity Acknowledgement (Appendix 9) prior to
return to play
§ Equipment evaluation and refitting should be considered prior to full return to contact for equipment laden sport.
Reducing Exposure to Head Trauma:
§ Athletics staff, student-athletes and officials will continue to emphasize that purposeful or flagrant head or neck contact in
any sport should not be permitted.
§ All coaches receive first aid/CPR training which includes review of the concussion and safety issues in sport.
§ A SEC Concussion Education poster is posted in all locker rooms.
§ Although “reducing” may be difficult to quantify, it is important to emphasize ways to minimize head trauma exposure.
Examples of minimizing head trauma exposure include, but are not limited to:
§ Adherence to Inter-Association Consensus: Year-Round Football Practice Contact Guidelines
§ Adherence to Inter-Association Consensus: Independent Medical Care Guidelines
§ Reducing gratuitous contact during practice
§ Taking a ‘safety first’ approach to sport
§ Taking the head out of contact
§ Coaching and student-athlete education regarding safe play and proper technique
Administrative:
§ UGAA will submit an institutional concussion management plan to the NCAA Concussion Safety Protocol Committee by
May 1 of each calendar year, accompanied by a written certificate of compliance signed by the director of athletics.
§ UGAA sports medicine staff members and other athletics healthcare providers will practice within the standards as
established for their professional practice (e.g., team physician7, certified athletic trainer8, physical therapist, nurse
practitioner, physician assistant, neurologist9, neuropsychologist10).
§ UGAA sports medicine staff members shall have the exclusive empowerment to determine management and return-to-play of
any ill or injured student-athlete, as he or she deems appropriate. Conflicts or concerns will be forwarded to the director of
sports medicine and the head team physician for remediation.
§
UGAA will document the incident, evaluation, continued management, and clearance of the student-athlete with a
concussion. Aggregate concussion numbers per sport will be reported to the director of athletics and deputy director
annually.
Approved by: ________________________ Medical Director
Fred Reifsteck, M.D.
Date: ________________
Approved by:
Date: _______________
_______________________ Neurosurgeon
Kim Walpert, M.D.
Approved by: ________________________ Dir. Sports Medicine
Ron Courson, ATC, PT, NREMT-I, CSCS
Date: ________________
Approved by:
_______________________ UGA Concussion Research Laboratory Directory
Julianne Schmidt, PhD, ATC
Date: ________________
Approved by:
_______________________ Neuropsychologist
Kate Finley, PhD
Date: ________________
Approved by: ________________________Emergency Medical Director
Glenn Henry, MA, EMT-P
Date: ________________
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 4th International Conference on Concussion in Sport Held in Zurich, November
2012. Clinical Journal of Sport Medicine, 2013; 23(2):89-117.
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 (Allen Press). 2014;49:245-265.
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. Sensitivity of the concussion assessment battery. Broglio SP, Macciocchi SN, Ferrara MS. Neurosurgery. 2007;60(6):1050-7.
14. Sensitivity and specificity of the impact test battery for concussion in athletes. Schatz P, Pardini JE, Lovell MR, Collins MW,
Podell K. Arch Clin Neuropsychol. 2006;21(1):91-99.
15. The "Value added" Of neurocognitive testing after sports-related concussion. Van Kampen DA, Lovell MR, Pardini JE, Collins
MW, Fu FH. Am J Sports Med. 2006;34(10):1630-1635.
16. One-year test-retest reliability of the online version of impact in high school athletes. Elbin RJ, Schatz P, Covassin T. Am J Sports
Med. 2011;39(11):2319-2324.
17. Long-Term Test-Retest Reliability of Baseline Cognitive Assessments Using ImPACT. Schatz P. Am J Sports Med. 2010; 38(1):
47-53.
18. Supporting the Student-Athlete’s return to classroom after a sport-related concussion. McGrath N. Journal of Athletic Training,
2010; 45(5):492-498.
19. 2002. Publication by six sports medicine organizations: AAFP, AAOS, ACSM, AMSSM, AOSSM, and AOASM.
Table of Appendices
Appendix 1: Concussion Management Checklist
Appendix 2: NCAA Concussion Information Fact Sheets
Appendix 3: Student-Athlete Concussion Statement
Appendix 4: Concussion Symptom Checklist
Appendix 5: Within 6-Hour Assessment Packet
Appendix 6: Concussion Patient Information Sheet
Appendix 7: Concussion Academic Notification Letter
Appendix 8: Exertional Testing Protocol Following Concussion
Appendix 9: Concussion Return to Athletic Activity Acknowledgement
Appendix 1
University of Georgia Sports Medicine
Concussion Management Checklist/CQI
Name: __________________________ 81____________ DOB: ________ Sport (position): ___________________
Injury Date: _________ Injury Time: ___:___ am/pm □ Game □ Practice □ Other: _____________________________
Mechanism of Injury: ________________________________________________________________________________
__________________________________________________________________________________________________
Pertinent PMH: □ History of prior concussions; if so, how many: ___ Date of most recent prior concussion: _______
□ LOC with prior concussion □ Hospitalization with prior concussion □ Prior brain imaging tests: _______________
Medications currently taking: __________________________________________________________________________
Additional Risk Factors: □ Migraines □ Learning disability/dyslexia □ ADD/ADHD
□ Seizure disorder
□ Depression, anxiety or other psychiatric disorder □ Family history of risk factors: __________________________
Within 6 hours PI testing: □ symptom checklist □ BESS □ SAC (Appendix 5)
Diagnostic testing: □ x-ray □ CT scan □ MRI Other: ____________________________________________________
Medical Referral:
□ Primary care sports medicine physician: Date: ______ Results: _________________________________________
□ Neurologist
Date: ______ Results: __________________________________________________________
□ Neurosurgeon
Date: ______ Results: __________________________________________________________
□ Neuropsychologist Date: ______ Results: __________________________________________________________
□ Other: __________ Date: ______ Results: __________________________________________________________
Date/Clinician:
□ Athlete Education: reviewed injury, common S&S of concussion, management plan (Appendix 6)
_____________
□ Concussion information sheet: provided to athlete/other responsible party(ies); signature obtained
_____________
□ Establish plan for follow up communication over next 24 hour
_____________
□ Tylenol provided and □ DHA Omega 3 supplementation provided (optional)
_____________
□ Parents/guardians contacted: individual spoken to: ___________________________________
_____________
□ Sport coach contacted: individual spoken to: _________________________________________
_____________
□ Academic support staff contacted: individual spoken to: _______________________________
_____________
□ Concussion information letter sent to academic support staff (Appendix 7)
_____________
□ 24-48 Hours PI testing: □ symptom checklist □ balance □ neuropsych: ________ □ King-Devick _____________
□ Symptom Checklist (Appendix 4): reviewed daily 1-on-1 with clinician: Date: __/__/__: Duration/Severity Scores
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
__/__/__: D:____ S:____
□ Asymptomatic on: __/__/__
_____________
Asymptomatic testing: □ symptom checklist □ balance □ Neuropsych: ________ □ King-Devick
_____________
□ Cleared by physician for Exertional Testing Protocol (Appendix 8)
_____________
□ Stage 1: Light exercise: ~<70% age-predicted maximal heart rate
_____________
□ Stage 2: Sport-specific activities without the threat of contact from others
_____________
□ Stage 3: Noncontact training involving others, resistance training
_____________
□ Stage 4: Unrestricted training
_____________
□ Stage 5: Non-contact or low-risk practice activities following completion of exertional protocol
_____________
□ Stage 6: Limited to full contact practice
_____________
□ Stage 7: Full Return to Play
_____________
□ Cleared by physician for return to practice activities
_____________
□ Non-contact practice activities: _________________________________________________
_____________
□ Contact practice activities: _____________________________________________________
_____________
Full RTP testing: □ symptom checklist □ balance □ neuropsych: ________ □ King-Devick _____________
□ Cleared by physician for return to competition
_____________
□ Return to competition: ________________________________________________________
_____________
□ Completed return to full athletic activity acknowledgement form; signature obtained (Appendix 9) _____________
6 Month PI testing: □ symptom checklist □ balance □ Neuropsych: ________ □ King-Devick _____________
Appendix 1 cont.
Comments: _______________________________________________________________________________
__________________________________________________________________________________________
Appendix 2
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.
Appendix 2 cont.
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.”
Appendix 2 cont.
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.
Appendix 3
University of Georgia Sports Medicine Student-­‐Athlete Concussion Statement *If there is anything on this sheet that you do not understand, please ask your athletic trainer or team physician to explain it to you. Student-­‐Athlete Name (printed):_______________________________________________________________ I have read and understand the NCAA-­‐CDC Concussion Fact Sheet for Student-­‐Athletes. If true, please check box. I am over 18 years old. If true, please check box. If you are not yet 18 years old, please consult your team physician or athletic trainer. Student-­‐
Athlete Initials By initialing, you confirm that you understand the following information that has been provided to you about concussions: A concussion is a brain injury caused by a blow to the head or body. A concussion can change the way your brain normally works, such as the ability to think, balance, and perform classwork. A concussion can range from mild to severe. A concussion can present itself differently for each athlete. A concussion can occur during practice or competition in any sport. A concussion can also occur outside of sport. A concussion can occur even if you do not lose consciousness. You can’t see a concussion, but you might notice some symptoms right away or hours/days after the injury. Exercise or activities that involve a lot of concentration may cause concussion symptoms to reappear or get worse. I will tell my sports medicine staff if I think I may have sustained a concussion. I will tell my sports medicine staff if I think one of my teammates may have sustained a concussion. I will not return to participation in a game, practice or other activity with symptoms. After a concussion, the brain needs time to heal. I understand that I am much more likely to have a repeat concussion if I return to play or practice before concussion symptoms go away. In rare cases, repeat concussions can cause permanent brain damage, and even death. Severe brain injury can change my whole life. __________________________________ Signature of Student-­‐Athlete _____________ Date Appendix 4
University of Georgia Sports Medicine
Concussion Symptom Checklist
Name______________________________
Day of Testing: ___/___/___
Baseline: ___/___/___
Symptom Response: Symptomatic (SRS): Day 1 2 3 4 5 6 7 ____
Symptom Response: Asymptomatic (SRA): Day 1 2 3 4 5 6 7 ____
Administration Mode: Patient Administered
Clinician Administered by: ______________________________
DURATION
SEVERITY
You should score yourself on the
following symptoms, based on
how you feel now.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
Sometimes
Always
Mild
Moderate
Severe
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
3. Neck Pain
1
2
3
4
5
6
1
2
3
4
5
6
4. Nausea or Vomiting
1
2
3
4
5
6
1
2
3
4
5
6
5. Dizziness
1
2
3
4
5
6
1
2
3
4
5
6
6. Blurred Vision
1
2
3
4
5
6
1
2
3
4
5
6
7. Balance Problems
1
2
3
4
5
6
1
2
3
4
5
6
8. Sensitivity to Light
1
2
3
4
5
6
1
2
3
4
5
6
9. Sensitivity to Noise
1
2
3
4
5
6
1
2
3
4
5
6
10. Feeling Slowed Down
1
2
3
4
5
6
1
2
3
4
5
6
11. Feeling like “in a fog”
1
2
3
4
5
6
1
2
3
4
5
6
12. “Don’t feel right”
1
2
3
4
5
6
1
2
3
4
5
6
13. Difficulty concentrating
1
2
3
4
5
6
1
2
3
4
5
6
14. Difficulty remembering
1
2
3
4
5
6
1
2
3
4
5
6
15. Fatigue or Low Energy
1
2
3
4
5
6
1
2
3
4
5
6
16. Confusion
1
2
3
4
5
6
1
2
3
4
5
6
17. Drowsiness
1
2
3
4
5
6
1
2
3
4
5
6
18. Trouble Falling Asleep
1
2
3
4
5
6
1
2
3
4
5
6
19. More Emotional
1
2
3
4
5
6
1
2
3
4
5
6
20. Irritability
1
2
3
4
5
6
1
2
3
4
5
6
21. Sadness
1
2
3
4
5
6
1
2
3
4
5
6
22. Nervous or Anxious
TOTAL DURATION SCORE:
TOTAL SEVERITY SCORE:
Do the symptoms get worse with physical activity?
Yes
No
NA Do the symptoms get worse with mental activity?
Yes
No
NA
How many hours did you sleep last night?________(hrs)
Comments:__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
1. Headache
2. “Pressure in Head”
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Briefly
Appendix 5
University of Georgia Concussion Evaluation Program Details & “Within 6 Hour” Assessment Packet Baseline Testing: All athletes should complete baseline testing every year. Incoming Athletes from Higher Risk Sports: Contact: Emily Miller All incoming athletes from the sports/events listed below will report to the Butts-­‐Mehre Concussion Research Laboratory (Butts-­‐Mehre) to complete baseline testing prior to their season of play: • Baseball • Football • Soccer • Basketball • Gymnastics • Softball Returning Athletes from Higher Risk Sports & All Athletes from Lower Risk Sports: Contact: Emily Miller All returning athletes (incoming baseline established) and athletes from the sports listed below will report to a location decided on by the staff Athletic Trainer and the Concussion Research Laboratory Team during their off season: • Cross Country • Tennis • Equestrian • Golf • Track & Field • Cheerleading
• Swimming & Diving • Volleyball Post-­‐Concussion: Contact: Emily Miller ([email protected]) Within 6 hours Assessment *Complete the following measures within 6 hours of injury (assessments attached)*: Injury information sheet Symptom Checklist Standardized Assessment of Concussion (SAC) Balance Error Scoring System (BESS) Daily Administration of Symptom Checklist Within 48 hours Appointment: Schedule appointment with team physician to occur within 48 hours of injury. The appointment time should be include the appointment time plus 40 minutes to complete CNS Vital Signs, SAC, BESS, & Graded Symptom Checklist (total time: 1 hour). Inform Concussion Research Laboratory Team of the injury & appointment time. We will dispatch someone to meet the athlete at their appointment and complete all measures before their appointment. Asymptomatic Appointment (Once symptoms fully resolve): Schedule an appointment with the Concussion Research Laboratory to complete concussion evaluation at Butts-­‐Mehre. Prior to Full Return to Play Appointment: Schedule a follow-­‐up appointment with the Concussion Research Laboratory to complete concussion evaluation at Butts-­‐Mehre. 6 Month post-­‐Injury Appointment: Schedule a follow-­‐up appointment with the Concussion Research Laboratory to complete concussion evaluation (location can vary). Contact Information: Julianne Schmidt Michelle Weber Concussion Research Laboratory Director Graduate Student Cell: (919) 699-­‐0055 Cell: (541) 974-­‐3396 Email: [email protected] Email: [email protected] Emily Miller Nicole Hoffman Project Coordinator Graduate Student Cell: (678) 643-­‐3085 Cell: (302) 540-­‐3032 Email: [email protected] or Email: [email protected] [email protected] CONCUSSION ASSESSMENT, RESEARCH AND EDUCATION (CARE) CONSORTIUM LONGITUDINAL CLINICAL STUDY CORE
Appendix 5 cont.
POST-INJURY PACKET
***Completed post-injury regardless of first assessment point***
INTERNAL USE ONLY
Internal School ID:__________________________
Today's Date (mm/dd/yyyy)_____________________
Institution/School Name_____________________
Examiner's name______________________________
Quesgen ID_______________________________
Examination Time (hh:mm)______________ AM PM
GUID ____________________________________
INJURY DESCRIPTION (completed by the clinician)
Injury Date _____/_____/_______ (mm/dd/yyyy)
Injury time ___________________ AM PM
The injury occurred during:
☐ Practice/Training ☐ Competition
☐Outside organized sport
If injured during sport, at what venue did it occur:
☐Home ☐Away ☐Neutral Site
Athlete is a US Military Academy Cadet/Midshipman ☐ Yes ☐No
For athletes at a College/University (ie nonmilitary academy), the concussion occurred
during which of the following (check one)?
Was the injury captured on film? ☐Yes ☐No
When during the event did the injury occur?
Football
Ice Hockey
______Quarter or ☐ OT _____ Period or ☐ OT
☐ Baseball
☐ Basketball
☐ Bowling
☐ CC / Track
☐ Diving
☐ Fencing
☐ Field Event
☐ Field Hockey
☐ Football
☐ Golf
☐ Gymnastics
☐ Ice Hockey
☐ Lacrosse
☐ Rifle
☐ Rowing / Crew
☐ Skiing
☐ Soccer
☐ Softball
☐ Swimming
☐ Tennis
☐ Volleyball
☐ Water polo
☐ Wrestling
☐ Other__________
If yes, was Hudl filming software used? ☐Yes ☐No
Lacrosse
____ ☐Quarter ☐Half or ☐ OT
Soccer
____Half or ☐ OT
All other sports
____________minutes into training/playing/competing when injury occurred ☐N/A
Mechanism of Injury
☐Tackled by opponent ☐Tackling an opponent ☐Blocking ☐Collision with opponent
☐Collision with teammate ☐Header with physical contact ☐Header without physical contact
☐Being checked ☐Checking ☐Contact with ball/puck/stick ☐Other__________________________
Injured athlete collided with:
☐ Other player's head/helmet ☐Other player's body (elbow, knee, etc) ☐Turf/Ground/Floor/Ice
☐ Field equipment (eg goal post) ☐Sideline equipment (eg bench) ☐Other______________________________
Impact location resulting in Injury:
☐ Head - Front ☐ Head - Left ☐ Head - Right ☐Head - Back ☐Head - Top ☐Trunk/Torso
☐Unknown ☐Other_________________________
Did the athlete immediately report the injury ☐Yes ☐No
If no, what was the date of reporting_____/_____/_______ (mm/dd/yyyy)
Was the athlete immediately removed from play ☐Yes ☐No ☐N/A
If not immediately identified / removed, how long did the athlete continue to play?______________ (min)
*****ALL INFORMATION WILL REMAIN CONFIDENTIAL*****
© NCAA-DoD Grand Alliance Post-Concussion Packet v.3
Page - 1 -
Appendix 5 cont.
Examiners Name:
Quesgen ID _______________________
Was there a delayed onset of symptoms after injury (ie initially normal, later symptomatic) ☐Yes ☐No
If yes, how long was the symptom onset after injury __________(min)
Once identified, was the athlete declared normal 15min after the injury? ☐Yes ☐No
Did the athlete return to activity on the same day? ☐Yes ☐No
Did the athlete have an alteration in mental status
at the time of injury (eg dazed, stunned, confused,
saw stars)?
☐Yes ☐No
Did the athlete experience post-traumatic
amnesia?
(Loss of memory after the injury)
Did the athlete lose consciousness? ☐Yes ☐No
If yes, for how long? ________________(sec)
If yes, was a LOC witnessed or self-reported?
☐Witness ☐Self-report
Did the athlete experience retro-grade amnesia?
(Loss of memory before the injury)
☐Yes ☐No
☐Yes ☐No
If yes, for what duration_________________(min)
If yes, for what duration________________(min)
Was the athlete taken to the hospital? ☐Yes ☐No
Was imaging completed? ☐None ☐MRI ☐CT
If yes, were there positive findings? ☐Yes ☐No
If positive findings, please describe: ________________________________________________________________
PLAYING SURFACE
Playing Surface:
☐ Grass – consistent surface ☐ Grass – irregular surface ☐ Field-Turf ☐ Astro-Turf ☐ Dirt ☐ Wood
☐ Asphalt/Concrete/Pool Deck ☐ Pool ☐ Ice ☐ Gymnastics/Wrestling mat ☐ Other_____________________
COMMENTS / ADDITIONAL INJURY INFORMATION
*****ALL INFORMATION WILL REMAIN CONFIDENTIAL*****
© NCAA-DoD Grand Alliance Post-Concussion Packet v.3
Page - 2 -
Appendix 5 cont.
University of Georgia Sports Medicine
Concussion Symptom Checklist
**Completed within 0-6 hours post Injury**
Name______________________________
Day of Testing: ___/___/___
Baseline: ___/___/___
Time: ___:___ AM PM
Symptom Response: Symptomatic (SRS): Day 1 2 3 4 5 6 7 ____
Symptom Response: Asymptomatic (SRA): Day 1 2 3 4 5 6 7 ____
Administration Mode: Patient Administered
Clinician Administered by: ______________________________
DURATION
SEVERITY
You should score yourself on the
following symptoms, based on
how you feel now.
1. Headache
2. “Pressure in Head”
3. Neck Pain
4. Nausea or Vomiting
5. Dizziness
6. Blurred Vision
7. Balance Problems
8. Sensitivity to Light
9. Sensitivity to Noise
10. Feeling Slowed Down
11. Feeling like “in a fog”
12. “Don’t feel right”
13. Difficulty concentrating
14. Difficulty remembering
15. Fatigue or Low Energy
16. Confusion
17. Drowsiness
18. Trouble Falling Asleep
19. More Emotional
20. Irritability
21. Sadness
22. Nervous or Anxious
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
Briefly
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
If yes à
Sometimes
Always
Mild
Moderate
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
1
2
3
4
5
6
1
2
3
TOTAL DURATION SCORE:
TOTAL SEVERITY SCORE:
Yes
No
Do the symptoms get worse with mental activity?
Yes
No
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Severe
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Do the symptoms get worse with physical activity?
How many hours did you sleep last night?________(hrs)
Comments:__________________________________________________________________________________________________________________________________
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Appendix 5 cont.
STANDARDIZED ASSESSMENT OF CONCUSSION - SAC
NAME:
TEAM:
EXAMINER:
DATE OF EXAM:
TIME:
EXAM (Circle One): BLINE INJURY
DAY1
FORM C
NEUROLOGIC SCREENING
POST-GAME
DAY2 DAY3 DAY5 DAY7 DAY90
No
Length:
No
Length:
No
Length:
NORMAL
LOSS OF CONSCIOUSNESS/
WITNESSED UNRESPONSIVENESS
POST-TRAUMATIC AMNESIA?
Poor recall of events after injury
RETROGRADE AMNESIA?
Poor recall of events before injury
INTRODUCTION:
I am going to ask you some questions.
Please listen carefully and give your best effort.
Yes
Yes
ABNORM
AL
STRENGTH -
ORIENTATION
What Month is it?
What’s the Date today?
What’s the Day of Week?
What Year is it?
What Time is it right now? (within 1 hr.)
0
0
0
0
0
1
1
1
1
1
Award 1 point for each correct answer.
ORIENTATION TOTAL SCORE
Š
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.
TRIAL 1
0 1
0 1
0 1
0 1
0 1
TRIAL 2
0 1
0 1
0 1
0 1
0 1
Right Upper Extremity
Left Upper Extremity
Right Lower Extremity
Left Lower Extremity
SENSATION
- examples:
FINGER-TO-NOSE/ROMBERG
COORDINATION - examples:
TANDEM WALK/ FINGER-NOSE-FINGER
IMMEDIATE MEMORY
LIST
BABY
MONKEY
PERFUME
SUNSET
IRON
TOTAL
Yes
TRIAL 3
0 1
0 1
0 1
0 1
0 1
Trials 2 & 3: I am going to repeat that list again.
Repeat back as many words as you can remember
in any order, even if you said the word before.
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.
If correct, go to next string length. If incorrect, read trial 2. 1 pt.
possible for each string length. Stop after incorrect on both trials.
1-4-2
6-8-3-1
4-9-1-5-3
3-7-6-5-1-9
6-5-8
3-4-8-1
6-8-2-5-1
9-2-6-5-1-4
Do not inform the subject that delayed recall will be tested.
DELAYED RECALL
If subject is not displaying or reporting symptoms,
conduct the following maneuvers to create
conditions under which symptoms likely to be
elicited and detected. These measures need not be
conducted if a subject is already displaying or
reporting any symptoms. If not conducted, allow 2
minutes to keep time delay constant before testing
Delayed Recall. These methods should be
administered for baseline testing of normal subjects.
EXERTIONAL MANEUVERS
5 Jumping Jacks
5 Push-Ups
5 Sit-ups
5 Knee Bends
0 1
Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan
CONCENTRATION TOTAL SCORE
EXERTIONAL MANEUVERS:
1
1
1
1
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.
Complete all 3 trials regardless of score on trial 1 & 2. 1 pt. for each
correct response. Total score equals sum across all 3 trials.
IMMEDIATE MEMORY TOTAL SCORE Š
0
0
0
0
Š
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.
BABY
MONKEY
PERFUME
SUNSET
DELAYED RECALL TOTAL SCORE
IRON
Š
SAC SCORING SUMMARY
Exertional Maneuvers & Neurologic Screening are important for
examination, but not incorporated into SAC Total Score.
ORIENTATION
IMMEDIATE MEMORY
CONCENTRATION
DELAYED RECALL
© 1998 MCCREA, KELLY & RANDOLPH
SAC TOTAL SCORE
/5
/ 15
/5
/5
Š
/30
Appendix 5 cont.
Start Time (hh:mm) ______________ AM PM
Date (mm/dd/yy): ______________________
Internal School ID_______________________
Assessment: <6hr post-injury
Balance Error Scoring System (BESS)
Which foot was tested (i.e. non-dominant foot): ☐ Left ☐ Right
Error Types
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
Athlete wore: ☐ Socks ☐No Socks
SCORE CARD:(# errors)
FIRM Surface
FOAM Surface
Double Leg Stance
(feet together)
Single Leg Stance
(non-dominant foot)
6. Remaining out of test position >5 sec
Tandem Stance
(non-dominant foot in back)
The BESS is calculated by adding one
error point for each error during the six
20-second tests.
Total Scores:
BESS TOTAL:
Assessment End Time (hh:mm) ______________ AM PM
Assessment not performed because: ☐ Athlete unavailable ☐ Athlete physical inability ☐ Athlete refused to complete
☐ Time point was not completed ☐ Symptoms worsened during assessment ☐ Other____________________
FATIGUE RATING - Following all assessments, please ask the athlete
Compared to how you normally feel and function each day, give a rating between 0 and 100 of how tired you feel
right now, with 0 being extremely exhausted and 100 being completely awake and
alert)____________________________
*****ALL INFORMATION WILL REMAIN CONFIDENTIAL*****
© NCAA-DoD Grand Alliance Post-Concussion Packet v.3
Page - 5 -
Appendix 6
University of Georgia Sports Medicine Concussion Patient Information Sheet Name: _______________________________________________: You have had a concussion and need to be watched closely for the next several days until you have completely recovered. The following information is regarding your treatment and recovery. What is a concussion? A concussion is a brain injury that is caused by a blow to the head or body. It may occur from contact with another player, hitting a hard surface such as the ground, floor, being hit by a piece of equipment such as a bat or ball, or a motor vehicle accident. A concussion can change the way your brain normally works. It can range from mild to severe and presents itself differently for each athlete. A concussion can happen even if you do not lose consciousness. What are the symptoms of a concussion? You can’t see a concussion, but you may notice some of the symptoms right away. Other symptoms can show up hours or days after the injury. Concussion symptoms may 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 • Difficulty getting to sleep or disrupted sleep • Slowed reaction time • Concentration or memory problems (forgetting game plays, facts, meeting times) How do you recover from a concussion? Your brain needs time to heal. Until you completely recover from your concussion, you will be held from all athletic activity. 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. 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. You will be evaluated by your physician initially and undergo some testing to determine how the concussion is affecting your ability to balance (e.g. Neurocom test) and process information (e.g. computer neuropsychological test). You will be followed daily by your athletic trainer to monitor your symptoms. When your symptoms are completely gone and your concussion testing results have returned to a normal level, you will perform some exertional tests under the supervision of your athletic trainer. Before returning to your sport, you must be re-­‐
evaluated by your physician and medically cleared for return. What to watch for? If you develop any new symptoms or increases in current symptoms, contact your athletic trainer or physician immediately at: (_________)_________________________. Medications: You have been given two medications to take as follows: • Acetaminophen (Tylenol): take 2 tablets every 6 hours as needed for headache (no more than 3 grams per day). • Martek DHA Omega 3: take 3 capsules three times a day Additional Instructions: DO NOT drive a car or motor scooter, drink alcohol, eat greasy or spicy foods, or take aspirin, Aleve, Advil or other anti-­‐inflammatory medications! Follow-­‐up: You will be seen for follow-­‐up examination by ________________________ on _______________ at ________________. Recommendations provided to ______________________________ by ______________________________ on / / . I acknowledge that I have received and understand the concussion information above and that I will notify a healthcare provider immediately with any changes in my signs and symptoms. ________________________________________________________________________________________ Student-­‐Athlete Name (print) Student-­‐Athlete Signature Date ________________________________________________________________________________________ Witness Name (print) Witness Signature Date Appendix 7
Sample Academic Notification Letter
Concussion Notification for ____________________
Student ID #____________
Date: / /
The University of Georgia Sports Medicine and Student Services/Academic Counseling Departments would like to inform
you that Name sustained a concussion on Date / / while provide brief concussion details (i.e. practice/competition, motor
vehicle accident, etc…). He/She was evaluated by Name of Physician, MD. Name will undergo additional concussion testing in
our sports concussion laboratory under the direction of Julianne Schmidt, PhD, ATC. Name is currently being held from all athletic
activities while symptomatic. He/she will be followed daily by our sports medicine staff. When his/her symptoms completely clear,
follow-up concussion testing will be performed to determine return to activity. Name will not return to any athletic activity until
he/she is completely symptom free and has been cleared by a physician.
A concussion is a type of traumatic brain injury (TBI) that results from a force to the head or body that causes the head and
brain to bounce around or twist in the skull, stretching and damaging brain cells and creating chemical changes in the brain. These
changes can lead to a set of symptoms affecting the student’s cognitive, physical, emotional, and sleep functions. Concussions affect
each individual differently. Most students will have symptoms that last for a few days or a week. A more serious concussion can last
for weeks, months or even longer.
Educators may be challenged with helping return a student to school still experiencing concussion symptoms as learning problems
and poor academic performance can occur. Name may require some academic accommodations during the recovery time from his/her
concussion, which may include excused absence from classes, rest periods during the school day, the extension of assignment
deadlines, postponement or staggering of tests, excuse from specific tests and assignments, extended testing time, accommodation for
oversensitivity to light and/or noise, excuse from physical exertion activities, use of a reader for assignments and testing, use of a note
taker or scribe, and use of a smaller, quieter examination room to reduce stimulation and distraction. You may find additional
information related to return to the classroom following a concussion at the web links below.
Any academic accommodations you may provide for name during this time would be greatly appreciated. Should you have any
questions or require further information, please do not hesitate to contact me at [email protected] or 706-542-9060 (work)
and/or name’s sport athletic trainer. Thank you in advance for your time and understanding with this circumstance.
Sincerely yours,
Ron Courson, ATC, PT, NREMT-I, CSCS
Sport Athletic Trainer
Senior Associate Athletic Director - Sports Medicine
cc: David Shipley, JD
Fred Reifsteck, MD
Alan Campbell, PhD
Julianne Schmidt, PhD
Greg McGarity
S-A Name
Carla Williams, PhD
Head Sport Coach
Ted White
CDC link: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf
NCAA link: http://www.ncaa.org/health-and-safety/medical-conditions/concussion-return-learn-guidelines
NATA link: http://www.nata.org/sites/default/files/attr-45-05-pg-492-498.pdf
Appendix 8
Exertional Testing Protocol Following Concussion
The following stages are not ALL to be performed on the same day. In some cases, stages 1 through 4 (or even 5) may be completed
on the same day, but typically will occur over multiple days. Stages 6 and 7 will each be performed on separate and subsequent days.
Student-athletes that present with symptoms at any stage should rest for 24 hours, be re-evaluated by the physician, and return to the
previous stage at the physician’s discretion.
No Activity
Once asymptomatic for 24 hours and cleared by medical staff
Symptom checklist, balance exam, and neuropsychological exam, and brief visual exam WNL
Exertional Testing Protocol
Stage 1: Light exercise: ~<70% age-predicted maximal heart rate
Stage 2: Sport-specific activities without the threat of contact from others
Stage 3: Noncontact training involving others, resistance training
Stage 4: Unrestricted training
If no change or increase in symptoms, move to next stage.
Stage 5: Non-contact or low-risk practice activities following completion of exertional protocol
If no change or increase in symptoms, move to next stage.
Stage 6: Limited to full contact practice
If no change or increase in symptoms, final return to play decision made by medical staff.
Stage 7: Full Return to Play
Athlete will be monitored by the medical staff for return of symptoms.
Appendix 9
University of Georgia Sports Medicine Concussion Return to Athletic Activity Acknowledgement □ I acknowledge that I have sustained a concussion. I understand that a concussion is a brain injury that is caused by a blow to the head or body. It may occur from contact with another player, hitting a hard surface such as the ground, floor, being hit by a piece of equipment such as a bat or ball, or a motor vehicle accident. A concussion can change the way your brain normally works. It can range from mild to severe and presents itself differently for each athlete. A concussion can happen even if you do not lose consciousness. □ I acknowledge that I have experienced signs and symptoms of concussion following my injury; however, all of my symptoms have fully resolved. I understand that concussion symptoms may 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 • Difficulty getting to sleep or disrupted sleep • Slowed reaction time • Concentration or memory problems (forgetting game plays, facts, meeting times) □ I acknowledge that I have recovered from my concussion. I understand that my brain needs time to heal following injury. I was held from athletic activity until I completely recovered. I understand that 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. I understand that 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. □ I acknowledge that I have been evaluated by a physician, undergone concussion testing, performed exertional tests, and have been medically cleared for return to athletic activity. □ I acknowledge that if I experience any concussion signs and symptoms, I will immediately report to a healthcare provider. I acknowledge that I fully understand the concussion information above, that the acknowledgements above are true and correct to the best of my knowledge, and that I will notify a healthcare provider and my coach immediately with any changes in my signs and symptoms. ____________________________________________________________ Student-­‐Athlete Name (print) Student-­‐Athlete Signature Date ____________________________________________________________ Witness Name (print) Witness Signature Date