2008 HEAD INJURY POSITION STATEMENT WYOMING HIGH SCHOOL ACTIVITIES ASSOCIATION
Introduction: The management of head injury in sports has evolved over the last decade. It has been estimated that 70% of traumatic sports-related deaths and 20% of sports-related disability are related to head and neck injuries. Furthermore, it is believed that 200,000 to 250,000 high school football players will suffer mild head injury annually. This translates into a risk of 15-30% of a mild head injury per season per player. In professional football, it has been reported that between 30-70% of players will return to play the same day after suffering a loss of consciousness (“knocked out”). Lastly, 8% of hockey players never received a medical evaluation after suffering a brain injury. Trends in the management of head injury have included a team approach, athlete stratification, the devastating consequences of repeat concussion, as well as the potential for subtle long-term disability. The responsibility for treating and preventing head injury in athletes is within the purview of team physicians, trainers, coaches, and physical therapists. Moreover, it is now being appreciated that young athletes as well as female athletes are more prone to lasting disability. The team taking care of athletes must fully appreciate that the athlete suffering a second or multiple concussions is a special case that warrants increased attention. Lastly, some of the effects of concussion can last for weeks or months and may need detailed psychological evaluation in order to be fully appreciated. Sideline Management A good rule of thumb is “When in doubt take them out”. In Wyoming, trainers and medical personnel are not available to cover all athletic contests. Therefore, the coach is the person in the best position to protect the player. The coach must be aware that the athlete may not be completely forthcoming in describing disability because he/she may fear being taken out of the game. Additionally, fans and other spectators may not fully appreciate the gravity of head injury especially the post-concussive syndrome. Some of the symptoms of concussion are vague and it may be unclear whether a loss of consciousness took place. Furthermore, the detection of post-concussive syndrome is getting increased attention. The post-concussive syndrome can last for weeks or months and these symptoms can be vague. It is important to exclude the athlete from further play until ALL symptoms have resolved. This may require an athlete to miss weeks or even months of play.
The following table includes signs (observed by staff) of concussion: Appears dazed or confused Confused about assignment Forgets plays Unsure of score, game, or opponent Moves clumsily Answers questions slowly Loss of consciousness Behavior changes Can’t recall hits or events prior to hit Personality Changes Personality Changes Doesn’t know opponent Poor concentration Can’t recall events after hit Vomiting
The following table includes symptoms (reported by athlete) of concussion: Headache Nausea Dizziness Confusion Memory problems Fuzzy vision (double) Sensitivity to light Sensitivity to noise Feeling “whoozy” Balance problems Poor concentration Feeling sluggish
The previous tables are not inclusive. It must be remembered that some signs of concussion and post-concussive syndrome can be very subtle. These may require detailed evaluation by a neurologist or neurosurgeon to fully evaluate. Assessment Tools Many tools are available to help Wyoming coaches protect their players. The Centers for Disease Control (CDC) have excellent information and tool kits available for coaches. The National Federation of High School Activities has partnered with the CDC to create “Heads UP: Concussion in High School Sports” which includes sideline assessment tools and brochures. Computer programs and specialized studies are available to help monitor the athlete in the post-concussive phase. These include IMPACT, Sentinel, CRI and ANAM. The WHSA is working with Wyoming Medical Center on the development of a head injury hotline. Coaches, trainers, and medical personnel can call this number and speak directly to medical personnel trained in head injury management. Return to Play The following recommendations are based on review of the latest data on head injury and a conservative approach to protect the player. 1. Determine whether a head injury has occurred. Again, the athlete may not volunteer information and coaches and trainers must fully assess the player before allowing continued play. In those cases where a head injury is believed not to have occurred but suspicion remains, a 15 minute trial of physical activity (push ups, sit ups, running in place) may be used to “clear” the player back to play. 2. No player should return to play the same day if a loss of consciousness or suspicion of a loss of conscious has occurred. It must be remembered that if a
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player cannot recall or is unclear about how he was injured, then a presumed “loss of consciousness has occurred”. Medical clearance by a medical professional/trainer is required prior to return to play. No player should be returned to play with ANY signs or symptoms listed in the tables above. It cannot be emphasized enough, that a player must be free of symptoms before returning to play. This can include a 15 minute physical exertion test. A player may be returned to play the same day if signs/symptoms of concussion resolve in 15 minutes, symptoms are not present after a 15 minute period of test exercise (running pushups etc), and no loss of consciousness has occurred. Given the high demand on coaches during a game, players experiencing signs/symptoms should be cleared by a medical professional/trainer prior to play. Immediate referral to emergency care is indicated for deteriorating status, persistent symptoms, or suspicion of neck injury. Any athlete, experiencing deteriorating symptoms or failing to improve after 10-15 minutes should be referred to an emergency room. Neck injury requires immobilization and transfer with spine precautions. Players experiencing a second concussion in a single season will not be returned to play the same day and will be referred for medical evaluation. It is recommended that players see a medical professional experienced in head injury management (neurologist or neurosurgeon). Since most seasons are three months, a second concussion occurring within three months of a previous one is considered in the “same” season.
Summary Second impact syndrome is a life-threatening condition that can affect players suffering a concussion. Female players and young players are more susceptible to second impact syndrome. Coaches, trainers, therapists, and team physicians are in the best position to protect the player. If there is any doubt about a player’s condition, then the player should be removed from play and not returned until symptoms have resolved. Evaluation by a trainer/medical profession is recommended for persistent symptoms, loss of consciousness, and deteriorating condition.
Matthew E. Mitchell, M.D. Casper Orthopedic Associates References: NFHS “Suggested Guidelines for Management of Head Trauma in Sports.”
CDC “Heads UP: Concussion in High School Sports” Ghiselli G., Schaadt G., McAllister D. On-the-field Evaluation of an Athlete with a Head or Neck Injury. Clinics in Sports Medicine 2003. Cantu R. Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications for Grading and Safe Return to Play. Journal of Athletic Training 2001. Guskiewicz K. et al. National Athletic Trainers’ Association Postion Statement: Management of Sports Related Concussion. Journal of Athletic Training. 2004.