Marist College Department of Athletics

MARIST COLLEGE DEPARTMENT OF ATHLETICS

Concussion/Mild Traumatic Brain Injury Management Protocol Revised: September 25, 2015

Purpose The Marist College Department of Athletics and Office of Sports Medicine recognizes that sport induced concussions or mild traumatic brain injury (MTBI) pose a significant health risk for those student-athletes participating in athletics at Marist College. With this in mind, the Office of Sports Medicine has implemented policies and procedures to assess and identify those student-athletes who have suffered a concussion/MTBI. The Office also recognizes that baseline neurocognitive testing on student-athletes who participate in those sports which have been identified as collision and or contact sports and/or who have had a history of concussions prior to entering Marist College will provide significant data for return to competition decisions. This baseline data along with physical examination, and/or further diagnostic testing will be used in conjunction in determining when it is safe for a student athlete to return to competition.

Concussion/MTBI Education In accordance with NCAA recommendations, student-athletes will be annually presented with educational materials in video and literature formats that provide information about the mechanisms of head injury, as well as the signs and symptoms of a Concussion/MTBI. They are then required to verify they reviewed the materials and had the opportunity to ask questions or request additional information (Appendix #1). Subsequently, it is required that all student-athletes electronically complete and sign the Marist College Sports Medicine Injury- Illness Acknowledgement Form (Appendix #2), a statement accepting the responsibility for truthful and honest reporting of his or her injuries and illnesses, including signs and symptoms of a Concussion/MTBI. Each coach (full and part-time) and Athletic Staff (Athletic Directors, Media Relations, etc.) that is employed by the College will be mandated to undergo a Concussion/MTBI information session annually. They will be supplied with a copy of this policy, as well as, the NCAA concussion fact sheet (Appendix #3). The session will be conducted by a member of the Office of Sports Medicine and an attendance log will be kept on file. This will be an information session, which will speak about symptoms, mechanisms and explain the College’s policy on Concussion/MTBI management. Attendees will be instructed that if he/she suspects one of their student-athletes has suffered a suspected head injury, they are immediately removed from practice or competition and evaluated by appropriate medical personnel. Each staff member will acknowledge their attendance and their understanding of this policy (Appendix #4). Due to the severe nature of a Concussion/MTBI, Marist College believes in a conservative approach for treatment. This includes the student-athlete self-reporting his or her symptoms after suffering a Concussion/MTBI. Self-reporting of symptoms plays an integral role in tracking the severity of his or her signs and symptoms completely honestly to the Sports Medicine Staff, Team Physician and/or Health Services Staff as soon as they present and each day following the injury.

Concussion/MTBI Definition A concussion/MTBI is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Another definition is a violent shaking or jarring action to brain, usually as a result of impact with an object or ground. This results in immediate partial or complete impairment of neurological function. 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. Concussions/MTBIs 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/MTBI typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

3. Concussion/MTBI may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Concussion/MTBI 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 however, post-concussive symptoms may be prolonged.

Signs and Symptoms of Concussion/MTBI All members of the Sports Medicine Staff (physicians, physician assistants, athletic trainers, student athletic trainers) and Department of Athletics coaches and staff all need to be aware of the signs and symptoms of a Concussion/MTBI to properly recognize and intervene on behalf of the student-athlete.

Physical Symptoms Cognitive Symptoms Emotionality Symptoms  Headache  Memory Loss  Irritability  Vision Difficulty  Attention Disorders  Sadness  Nausea  Reasoning difficulty  Nervousness  Dizziness  Feeling like in a fog  Sleep Disturbances  Balance Difficulties  Slowed reaction time  Light sensitivity  Fatigue

Pre-Participation Assessment (Baseline Testing) A baseline assessment consisting of both subjective and objective tests, standardized cognitive and balance assessments, and physical evaluation will be performed on student-athletes deemed “high risk”. All incoming freshman or those first time entering Marist College student-athletes who are participating in those sports which have been identified as a contact or collision sport and /or who have had a previous history of concussions as identified by their health history will have a computerized baseline neurocognitive test (ImPACT Testing) and a Sport Concussion Assessment Tool 3 (SCAT3) (includes Standard Assessment of Concussion - SAC, Balance Error Scoring System - BESS, Glasgow Coma Scale, Maddocks Score) performed as part of their athletic medical screening. In 2014, the Marist College Office of Sports Medicine began utilizing the ATS Software concussion management module. The ATS Software system is a Windows and internet based computer program which consists of modules designed to compile the results of the SCAT3. The SCAT3 is a series of questions and examinations testing: Orientation, Immediate Memory, Concentration, and Delayed Memory to measure the immediate neurocognitive effects and balance abilities of a student-athlete with a suspected Concussion/MTBI. The sports which currently undergo SCAT3, in addition to ImPACT, testing are as follows: - M/W Soccer - Football - M/W Lacrosse - M/W Basketball - W Volleyball - Waterpolo

All remaining Marist College teams will undergo baseline ImPACT Testing when the student-athletes are incoming freshmen or first-time participants (including rugby and ice hockey).

On-Field or Sideline Evaluation of Acute Concussion/MTBI When a player shows any features of a Concussion/MTBI (see flowchart; Appendix #5): 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 healthcare provider arranged.  Activation of the Emergency Medical Services (EMS) should be performed for student- athletes with one or more of the following signs and/symptoms:

 Loss of consciousness (>30 sec.)  High index of suspicion of spine or skull injury  Deterioration of level of consciousness  Seizure activity  Evidence of hemodynamic instability/deterioration of vital signs

c. Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT3 (Appendix #6). 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 (see Post-Concussion/Mild Traumatic Brain Injury (MTBI) Take Home Instructions; Appendix #7). e. A PLAYER WITH DIAGNOSED CONCUSSION/MTBI SHOULD NOT BE ALLOWED TO RETURN TO PLAY ON THE DAY OF INJURY. 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 SCAT3, which incorporates the Maddock’s questions and the Standard Assessment of Concussion (SAC).

f. For any student-athlete sustaining a concussion that was not the result of a team sponsored event (game, practice, team lifting, team conditioning) the athlete will be referred to a physician within his/her family health insurance network (any cost will be the athlete’s responsibility) and will have to give the sports medicine staff documentation of the visit and of the physician’s recommendations for return to play before beginning the Marist Sports Medicine return to play protocol. There will be NO exceptions for this circumstance.

Off-Field Immediate Referral In the event the student-athlete shows signs of deterioration from the status originally assessed on the field, an emergency of the field assessment is required and subsequent immediate referral to an appropriate emergency treatment facility is warranted with any of the following findings:

 Deterioration of neurological signs such as motor, sensory and cranial nerve deficits subsequent to initial on-field assessment  Documented loss of consciousness  Deteriorating level of consciousness  Persistent vomiting  Post-concussion symptoms that worsen

It should also be recognized that the appearance of symptoms or cognitive deficit might be delayed several hours following a concussive episode and that concussion should be seen as an evolving injury in the acute stage. Post-Concussion/MTBI 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. The majority (80-90%) of injuries will recover spontaneously over several days (average 7-10 days), although the recovery time may be longer in children and adolescents. 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 symptomatic, following an injury, it is important to emphasize to the student-athlete that physical and cognitive rest is required. Activities that require concentration and attention (ie. 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. Follow-up Care In the event of a concussion, follow-up care and proper education is critical. Due to the necessity of serial monitoring for deterioration of symptoms, the student-athlete will be released under the care of an on-campus emergency contact when discharged from the care of the Sports Medicine Staff. The Concussion/MTBI Take- Home Instructions will be explained and given to both the concussed student-athlete as well as the on-campus emergency contact. Pertinent contact information will be provided in addition to scheduled follow up appointments. Subsequent Testing Concussed student-athletes will be assessed daily with the assistance of the SCAT3 until released by a member of the Sports Medicine Staff. Student athletes will be tested using the ImPACT Testing within 24 hours of a Concussion/MTBI episode (immediately following will be best case). The athlete will again be ImPACT tested once they report being asymptomatic for 24-hours (Stage 2 of Return to Play Protocol-see below) along with BESS and SCAT3. Multiple Concussions/MTBIs Student-athletes who experience two (2) concussions in a season will consult with the Team Physician regarding how and when to proceed with returning to participation. Outside experts may be consulted to achieve the best possible outcome for the student-athlete but the Team Physician will have the final decision on return to play.

Prolonged Recovery of Concussions/MTBIs Persistent symptoms (>10 days) are generally reported in 10-15% of concussions/MTBIs. In general, symptoms are not specific to concussion and it is important to consider other pathologies. Cases of concussion/MTBI in sport where clinical recovery falls outside the expected window (ie, 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussions/MTBIs (Neurologist).

Modifying Factors in Concussion/MTBI Management A range of ‘modifying’ may influence the investigation and management of concussion/MTBI and, in some cases, may predict the potential for prolonged or persistent symptoms. These modifiers would be important to consider in a detailed concussion/MTBI history and are outlined below. Factors Modifier Symptoms Number Duration (>10 days) Severity Signs Prolonged loss of consciousness (LOC) (>1 min) Amnesia Sequelae Concussive convulsions Temporal Frequency – repeated concussions/MTBIs over time Timing – injuries close together in time ‘Recency’ – recent concussion or MTBI Threshold Repeated concussion/MTBIs occurring with progressively less ImPACT force or slower recovery after each successive concussion/MTBI Age Child and adolescent (<18 years old) Comorbidities and Migraine, depression or other mental health disorders, attention deficit Premorbidities hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Psychoactive drugs, anticoagulants Behavioral Dangerous style of play Sport High-risk activity, contact and collision sport, high sporting level .

Graduated Return to Play (RTP) Protocol Return-to-play is the process of deciding when an injured or ill student-athlete may safely return to practice or competition. It is the goal of Marist College to return an injured or ill student-athlete to practice or competition without putting the individual or others at undue risk for injury or illness. RTP protocol following a Concussion/MTBI follows a stepwise process as outlined in Appendix #8. With this stepwise progression, the student-athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 hours so that a student-athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussive symptoms occur while the in the stepwise program, then the student-athlete should drop back to the previous asymptomatic level and try to progress again after a further 24 hour period of rest. The Sports Medicine Staff will be in direct contact with the Team Physician while progressing the student-athlete through the program. It is important to note that this timeline could last over a period of days, weeks, months or ultimately result in potential medical disqualification from the participation in Marist College Athletics. An important consideration in RTP is that concussed student-athletes should not only be symptom-free, but also they should not be taking any pharmacological agents/medications that may mask or modify the symptoms of concussion/MTBI.

Graduated Return to Learn Protocol It is well documented that a student-athlete who is experiencing post-concussion symptoms is in need of academic modifications. Whether it is an absence from class altogether, limiting visual stimuli, auditory stimuli, or outside assignments, proper accommodations must be made and followed by those involved. Concussion can happen to anyone and can affect a student’s chances for success in college. “Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction“(Harmon et al., 2013). Cognitive and physical rest has become the cornerstone of concussion management (Guskiewicz et al., 2001; McCrory et al., 2008; McCrory et al., 2013, Harmon et al., 2013). Recent research suggests that cognitive rest is a critical element of successful concussion management and can significantly shorten the recovery period (Moser et al., 2012). Elements of cognitive rest can include prohibition of school attendance, homework, reading, video games, texting, computer time or television watching. Resumption of these activities should be gradual and is dependent on the absence of concussion- related symptoms. When advising college student-athletes on when and how to best resume their regular academic work, the follow points are considered.

 The most current medical evidence recommends an individualized approach involving a gradual return to academic activities in a manner that does not prolong or exacerbate symptoms.  Students should return to full academic function and be asymptomatic before returning to unrestricted physical activity.  The stress and anxiety that students experience around missed classes and assignments can be mitigated with appropriate short-term academic accommodations and support from professors, deans and the Office of Special Services.  Ongoing medical supervision with coordinated care between the Office of Health Services, the Counseling Center, deans, physicians, and Sports Medicine staff when appropriate, is essential.  For students with symptoms lasting longer than 3 weeks, further medical management considerations and accommodations may be needed.

Initially students will be advised to rest the brain and body for a 24-72 hour period. This means not attending classes, doing homework, listening to lectures, watching videos, or using the computer or cell phone. Students will be encouraged to communicate with their professors about their status. Any student- athlete who requires academic modifications following a concussion will be referred to the Center for Student-Athlete Enhancement (CSAE) with their classroom restrictions form (Appendix #9). The CSAE will contact the student-athletes’ professors and make them aware of the situation so they can make appropriate accommodations in order to make up the classwork. The Sports Medicine staff will continue to be in contact with the CSAE throughout the process in order to facilitate the optimal return to learn protocol for each student- athlete. Students will be encouraged to sleep, eat and hydrate well, spend quiet time with friends/family, listen to calming audio for short periods, take short walks or practice some relaxation techniques. Students will be told to stop any of these activities if concussion symptoms worsen. Students will return for follow-up evaluation within 24-48 hours. At this visit, a thorough symptom review will be done and any other relevant testing. Restrictions on academic work will be kept the same or modified depending on the findings. Students will continue to return periodically (usually every few days) for repeated assessments. When the measures obtained from these markers show significant improvement, the student will be advised to resume class attendance This program is to be used as a minimum requirement for the student-athlete to follow, and each student-athlete will be encouraged to use their best judgment in order to determine if they are able to do more than what is required of them. This process will be individualized to each student’s symptoms and deficiencies. A return to learn management team has been put into place that can assist the student-athlete and family in situations that may need further attention. If a student-athlete is having concerns or issues in regards to their recovery from a head injury, they can contact the team chair in order to schedule a meeting with the entire team.

This team is made up of: Coordinator of Sports Medicine: Team Chair Director of the Center for Student-Athlete Enhancement Assistant Athletic Trainer Team Physician

The Coordinator of Sports Medicine, along with their full-time staff members will oversee the return to learn process. All student-athletes will have a full-time staff member responsible for overseeing their recovery, regardless of who is their team Athletic Trainer.

Administrative Marist College Sports Medicine will have on file and annually update an emergency action plan (EAP) 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. A list of personal who have completed this training will be kept on file within the Office of Sports Medicine.

Marist College will submit an institutional concussion/MTBI management plan to the MAAC and NCAA Concussion Safety Protocol Committee for each calendar year, accompanied by a written certificate of compliance signed by the Director of Athletics.

Marist College sports medicine staff members and other athletics healthcare providers will practice within the standards as established for their professional practice.

Marist College 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 Coordinator of Sports Medicine and as needed, the head team physician, for remediation.

Marist College sports medicine staff will document the incident, evaluation, continued management and clearance of the student-athletes with a concussion. Once medically cleared for return to play, the student- athlete will be required to complete the Concussion Return to Athletic Activity Acknowledgement Form (Appendix #10).

Reference Documents

1. 2014-2015 NCAA Sports Medicine Handbook. National Collegiate Athletic Association.

2. National Athletic Trainers’ Association Position Statement: Emergency Planning in Athletics. Journal of Athletic Training, 2002; 37(1): 99-104.

3. Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics. National Athletic Trainers’ Association, 2000. Revised 2003, 2007, 2010.

4. Consensus Statement on Concussion in Sport: 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clinical Journal of Sports Medicine, 2013; 23(2): 89-117.

5. National Athletic Trainers’ Association Position Statement: Management of Sports-Related Concussion. Journal of Athletic Training, 2014; 49(1): 245-265.

6. Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges. Journal of Athletic Training, 2014; 49(1): 128-137.

Table of Appendices: Appendix 1: NCAA Student-Athlete Concussion/MTBI Fact Sheet Appendix 2: Injury/Illness Acknowledgement Form Appendix 3: NCAA Concussion Information Fact Sheets Appendix 4: Staff Education Verification Form Appendix 5: Concussion/MTBI Management Flow-Chart Appendix 6: SCAT3 Appendix 7: Post-Concussion/MTBI Take Home Information and Instructions Appendix 8: Return to Play Protocol Appendix 9: Return to Learn Classroom Notification/Restrictions Appendix 10: Concussion Return to Athletic Activity Acknowledgement

Marist College (All) NCAA Concussion/MTBI Fact Sheet Form

Section Sub-Section Q#

Rough layout/worksheet only. Screen &reports will appear differently NCAA Concussion Fact Sheet for Student-Athletes 1 1.10 1 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

AthleteFormPreview.rpt 09/23/2015 1:45:11PM 09/23/2015 (All) NCAA Concussion/MTBI Fact Sheet

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: * NCAA Health-Safety * CDC Concussion Page By signing below I certify that I have read the NCAA concussion sheet and understand the 1 1.10 6 information as presented.

AthleteFormPreview.rpt 09/23/2015 1:45:11PM 09/23/2015 Marist College (All) Injury & Illness Reporting Acknowledgement Form Form

Section Sub-Section Q#

Rough layout/worksheet only. Screen &reports will appear differently INJURY AND ILLNESS REPORTING ACKNOWLEDGEMENT 1 1.10 1 I acknowledge that I have to be an active participant in my own healthcare. As such, I have the direct 1 1.10 1 responsibility for reporting all of my injuries and illnesses to the sports medicine staff of my institution (e.g., team physician, athletic training staff). I recognize that my true physical condition is dependent upon an accurate medical history and a full disclosure of any symptoms, complaints, prior injuries and/or disabilities experienced. I hereby affirm that I have fully disclosed in writing any prior medical conditions and will also disclose any future conditions to the sports medicine staff at my institution. 1 1.20 2 I further understand that there is a possibility that participation in my sport may result in a concussion 1 1.20 2 and/or mild traumatic brain injury (MTBI). I have been provided with education on Concussions/MTBIs and understand the importance of immediately reporting symptoms of a Concussion/MTBI to a member of the sports medicine staff. 1 1.30 3 By signing below, I acknowledge that my institution has provided me with specific educational 1 1.30 3 materials on what a Concussion/MTBI is, all inherit risks of athletic participation within sport(s) and given me an opportunity to ask questions about areas and issues that are not clear to me on this issue.

I have read the above and agree that the statements are accurate.

AthleteFormPreview.rpt 09/23/2015 1:43:57PM 09/23/2015 CONCUSSION A fact sheet for student-athletes

What is a concussion? What are the symptoms of a A concussion is a brain injury that: concussion? • Is caused by a blow to the head or body. You can’t see a concussion, but you might notice some of the symptoms – From contact with another player, hitting a hard surface such right away. Other symptoms can show up hours or days after the injury. as the ground, ice or floor, or being hit by a piece of equipment Concussion symptoms include: such as a bat, lacrosse stick or field hockey ball. • Amnesia. • Can change the way your brain normally works. • Confusion. • Can range from mild to severe. • Headache. • Presents itself differently for each athlete. • Loss of consciousness. • Can occur during practice or competition in ANY sport. • Balance problems or dizziness. • Can happen even if you do not lose consciousness. • Double or fuzzy vision. • Sensitivity to light or noise. How can I prevent a concussion? • Nausea (feeling that you might vomit). Basic steps you can take to protect yourself from concussion: • Feeling sluggish, foggy or groggy. • Do not initiate contact with your head or helmet. You can still get • Feeling unusually irritable. a concussion if you are wearing a helmet. • Concentration or memory problems (forgetting game plays, facts, • Avoid striking an opponent in the head. Undercutting, flying meeting times). elbows, stepping on a head, checking an unprotected opponent, • Slowed reaction time. and sticks to the head all cause concussions. Exercise or activities that involve a lot of concentration, such as • Follow your athletics department’s rules for safety and the rules of studying, working on the computer, or playing video games may cause the sport. concussion symptoms (such as headache or tiredness) to reappear or • Practice good sportsmanship at all times. get worse. • Practice and perfect the skills of the sport.

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 What is a concussion? • A concussion is a brain injury. A concussion is a brain injury that may be caused by a blow to the • All concussions are serious. head, face, neck or elsewhere on the body with an “impulsive” force • Concussions can occur without loss of consciousness or other transmitted to the head. Concussions can also result from hitting a obvious signs. hard surface such as the ground, ice or floor, from players colliding • Concussions can occur from blows to the body as well as to the head. with each other or being hit by a piece of equipment such as a bat, • Concussions can occur in any sport. lacrosse stick or field hockey ball. • Recognition and proper response to concussions when they first occur can help prevent further injury or even death. Recognizing a possible concussion • Athletes may not report their symptoms for fear of losing playing time. To help recognize a concussion, watch for the following two events • Athletes can still get a concussion even if they are wearing a helmet. among your student-athletes during both games and practices: • Data from the NCAA Injury Surveillance System suggests that 1. A forceful blow to the head or body that results in rapid concussions represent 5 to 18 percent of all reported injuries, movement of the head; depending on the sport. -AND- 2. Any change in the student-athlete’s behavior, thinking or physical functioning (see signs and symptoms).

Signs and Symptoms Signs Observed By Coaching Staff Symptoms Reported By Student-Athlete • Appears dazed or stunned. • Headache or “pressure” in head. • Is confused about assignment or position. • Nausea or vomiting. • Forgets plays. • Balance problems or dizziness. • Is unsure of game, score or opponent. • Double or blurry vision. • Moves clumsily. • Sensitivity to light. • Answers questions slowly. • Sensitivity to noise. • Loses consciousness (even briefly). • Feeling sluggish, hazy, foggy or groggy. • Shows behavior or personality changes. • Concentration or memory problems. • Can’t recall events before hit or fall. • Confusion. • Can’t recall events after hit or fall. • 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 IF A CONCUSSION IS SUSPECTED: SUSTAINED A CONCUSSION: 1. Remove the student-athlete from play. Look for the signs and Take him/her out of play immediately and allow adequate time for symptoms of concussion if your student-athlete has experienced a evaluation by a health care professional experienced in evaluating blow to the head. Do not allow the student-athlete to just “shake it for concussion. off.” Each individual athlete will respond to concussions differently. An athlete who exhibits signs, symptoms or behaviors consistent with 2. Ensure that the student-athlete is evaluated right away by a concussion, either at rest or during exertion, should be removed an appropriate health care professional. Do not try to judge immediately from practice or competition and should not return to the severity of the injury yourself. Immediately refer the student- play until cleared by an appropriate health care professional. Sports athlete to the appropriate athletics medical staff, such as a certified have injury timeouts and player substitutions so that student-athletes athletic trainer, team physician or health care professional can get checked out. 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.

As a member of the Marist College Athletic Department, I acknowledge that I have attended a training session in regards to concussion/MTBI management at Marist College. I further attest to understanding my role in the identification and management of a potential head injury.

Printed Name: Signature: Date: 1. ______2. ______3. ______4. ______5. ______6. ______7. ______8. ______9. ______10. ______11. ______12. ______13. ______14. ______15. ______16. ______17. ______18. ______19. ______20. ______21. ______Marist College Sports Medicine: Concussion/MTBI Flow Sheet Preseason baseline testing with ImPACT and ATS Software (SCAT3, SAC, BESS): M/W Soccer, Football, W Volleyball, M/W Basketball, M/W Lacrosse, Waterpolo or history of multiple concussions/MTBIs; remaining sports ImPACT only

INJURY

Prolonged loss of consciousness (> 30 sec.) and/or High index of suspicion of spine or skull injury and/or Deterioration of level of consciousness and/or Seizure activity and/or Evidence of hemodynamic instability/deterioration of vital signs

(+) (‐)

EMS Activation and transport to Repeat SCAT3 and perform Physical Exam on side‐line or in SM Ofice within 15 minutes of hospital with injury; Compare to baseline results spine precautions Exertional (Abnormal) (Normal) Maneuvers Test Severe Symptoms or (Abnormal) (Normal) Rapid Mild to Moderate symptoms and Deterioration reliable person to monitor student‐athlete at home Return to Competition Discharge home with reliable observer and concussion/MTBI Information Sheet; NO DRIVING

Wait 24 hours following Symptoms or baseline symptom resolution; Within 48 hours re‐evaluate with resolve <7‐10 days Initiate Return to Play (RTP) ImPACT and ATS Protocol (see attached) software; Check for post‐concussive Further work‐up indicated; symptoms; Symptoms or baseline unresolved >7‐10 days Referral to neurologist Downloaded from bjsm.bmj.com on March 25, 2013 - Published by group.bmj.com SCAT3™ Sport Concussion Assessment Tool – 3rd edition For use by medical professionals only

name Date / Time of Injury: examiner: Date of Assessment:

1 What is the SCAT3? 1 the SCAt3 is a standardized tool for evaluating injured athletes for concussion glasgow coma scale (gCS) and can be used in athletes aged from 13 years and older. it supersedes the orig- Best eye response (e) inal SCAt and the SCAt2 published in 2005 and 2009, respectively 2. For younger no eye opening 1 persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed for use by medical professionals. If you are not qualifi ed, please use the Sport eye opening in response to pain 2 Concussion recognition tool1. preseason baseline testing with the SCAt3 can be eye opening to speech 3 helpful for interpreting post-injury test scores. eyes opening spontaneously 4

Specifi c instructions for use of the SCAT3 are provided on page 3. If you are not Best verbal response (v) familiar with the SCAt3, please read through these instructions carefully. this no verbal response 1 tool may be freely copied in its current form for distribution to individuals, teams, incomprehensible sounds 2 groups and organizations. Any revision or any reproduction in a digital form requires approval by the Concussion in Sport Group. inappropriate words 3 NOTE: the diagnosis of a concussion is a clinical judgment, ideally made by a Confused 4 medical professional. the SCAt3 should not be used solely to make, or exclude, oriented 5 the diagnosis of concussion in the absence of clinical judgement. An athlete may have a concussion even if their SCAt3 is “normal”. Best motor response (m) no motor response 1 extension to pain 2 What is a concussion? Abnormal fl exion to pain 3 A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specifi c signs and / or symptoms (some Flexion / Withdrawal to pain 4 examples listed below) and most often does not involve loss of consciousness. localizes to pain 5 Concussion should be suspected in the presence of any one or more of the obeys commands 6 following: - Symptoms (e.g., headache), or glasgow Coma score (e + v + m) of 15 - Physical signs (e.g., unsteadiness), or GCS should be recorded for all athletes in case of subsequent deterioration. - Impaired brain function (e.g. confusion) or - Abnormal behaviour (e.g., change in personality). 2 maddocks Score3 Sideline ASSeSSmenT “I am going to ask you a few questions, please listen carefully and give your best effort.” Modifi ed Maddocks questions (1 point for each correct answer) indications for emergency management What venue are we at today? 0 1 noTe: A hit to the head can sometimes be associated with a more serious brain injury. Any of the following warrants consideration of activating emergency pro- Which half is it now? 0 1 cedures and urgent transportation to the nearest hospital: Who scored last in this match? 0 1 -Glasgow Coma score less than 15 What team did you play last week / game? 0 1 - Deteriorating mental status Did your team win the last game? 0 1 - potential spinal injury -progressive, worsening symptoms or new neurologic signs maddocks score of 5 Maddocks score is validated for sideline diagnosis of concussion only and is not used for serial testing. Potential signs of concussion? if any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical professional and should not be permitted to return to sport the same day if a notes: mechanism of injury (“tell me what happened”?): concussion is suspected.

Any loss of consciousness? Y n “if so, how long?“ Balance or motor incoordination (stumbles, slow / laboured movements, etc.)? Y n Disorientation or confusion (inability to respond appropriately to questions)? Y n loss of memory: Y n “if so, how long?“ “Before or after the injury?" Any athlete with a suspected concussion should be removed Blank or vacant look: Y n From PlAy, medically assessed, monitored for deterioration Visible facial injury in combination with any of the above: Y n (i.e., should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. no athlete diagnosed with concussion should be returned to sports participation on the day of injury.

Background Cognitive & Physical Evaluation

Name: Date: 4 Cognitive assessment Examiner: Standardized Assessment of Concussion (SAC) 4 S p o r t / t e a m / s c h o o l : Date / time of injury: Orientation (1 point for each correct answer) Age: Gender: M F Years of education completed: What month is it? 0 1 Dominant hand: right left neither What is the date today? 0 1 How many concussions do you think you have had in the past? What is the day of the week? 0 1 When was the most recent concussion? What year is it? 0 1 How long was your recovery from the most recent concussion? What time is it right now? (within 1 hour) 0 1 Have you ever been hospitalized or had medical imaging done for Y N Orientation score of 5 a head injury? Have you ever been diagnosed with headaches or migraines? Y N Immediate memory Do you have a learning disability, dyslexia, ADD / ADHD? Y N List Trial 1 Trial 2 Trial 3 Alternative word list Have you ever been diagnosed with depression, anxiety Y N elbow 0 1 0 1 0 1 candle baby finger or other psychiatric disorder? apple 0 1 0 1 0 1 paper monkey penny Has anyone in your family ever been diagnosed with Y N any of these problems? carpet 0 1 0 1 0 1 sugar perfume blanket saddle 0 1 0 1 0 1 sandwich sunset lemon Are you on any medications? If yes, please list: Y N bubble 0 1 0 1 0 1 wagon iron insect Total SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. Immediate memory score total of 15

Symptom Evaluation Concentration: Digits Backward List Trial 1 Alternative digit list 3 How do you feel? 4-9-3 0 1 6-2-9 5-2-6 4-1-5 “You should score yourself on the following symptoms, based on how you feel now”. 3-8-1-4 0 1 3-2-7-9 1-7-9-5 4-9-6-8 6-2-9-7-1 0 1 1-5-2-8-6 3-8-5-2-7 6-1-8-4-3 none mild moderate severe 7-1-8-4-6-2 0 1 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 Headache 0 1 2 3 4 5 6 Total of 4 “Pressure in head” 0 1 2 3 4 5 6 Neck Pain 0 1 2 3 4 5 6 Concentration: Month in Reverse Order (1 pt. for entire sequence correct) Nausea or vomiting 0 1 2 3 4 5 6 Dec-Nov-Oct-Sept-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 0 1 Dizziness 0 1 2 3 4 5 6 Concentration score of 5 Blurred vision 0 1 2 3 4 5 6 Balance problems 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6 Sensitivity to noise 0 1 2 3 4 5 6 5 Neck Examination: Feeling slowed down 0 1 2 3 4 5 6 Range of motion tenderness upper and lower limb sensation & strength Feeling like “in a fog“ 0 1 2 3 4 5 6 Findings: “Don’t feel right” 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 6 Balance examination Fatigue or low energy 0 1 2 3 4 5 6 Do one or both of the following tests. Confusion 0 1 2 3 4 5 6 Footwear (shoes, barefoot, braces, tape, etc.) Drowsiness 0 1 2 3 4 5 6 5 Trouble falling asleep 0 1 2 3 4 5 6 Modified Balance Error Scoring System (BESS) testing More emotional 0 1 2 3 4 5 6 Which foot was tested (i.e. which is the non-dominant foot) Left Right Irritability 0 1 2 3 4 5 6 Testing surface (hard floor, field, etc.) Sadness 0 1 2 3 4 5 6 Condition Nervous or Anxious 0 1 2 3 4 5 6 Double leg stance: Errors Single leg stance (non-dominant foot): Errors Total number of symptoms (Maximum possible 22) Tandem stance (non-dominant foot at back): Errors Symptom severity score (Maximum possible 132) And / Or Y N Do the symptoms get worse with physical activity? Tandem gait6,7 Do the symptoms get worse with mental activity? Y N Time (best of 4 trials): seconds self rated self rated and clinician monitored clinician interview self rated with parent input Overall rating: If you know the athlete well prior to the injury, how different is 7 Coordination examination the athlete acting compared to his / her usual self? Upper limb coordination Please circle one response: Which arm was tested: Left Right no different very different unsure N/A Coordination score of 1

Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about 8 SAC Delayed Recall4 an athlete’s readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to Delayed recall score of 5 consider repeat evaluation in the acute assessment of concussion.

Instructions Balance testing – types of errors 1. Hands lifted off iliac crest Words in Italics throughout the SCAT3 are the instructions given to the athlete by 2. Opening eyes the tester. 3. Step, stumble, or fall 4. Moving hip into > 30 degrees abduction 5. Lifting forefoot or heel Symptom Scale 6. Remaining out of test position > 5 sec

“You should score yourself on the following symptoms, based on how you feel now”. Each of the 20-second trials is scored by counting the errors, or deviations from To be completed by the athlete. In situations where the symptom scale is being the proper stance, accumulated by the athlete. The examiner will begin counting completed after exercise, it should still be done in a resting state, at least 10 minutes errors only after the individual has assumed the proper start position. The modified post exercise. BESS is calculated by adding one error point for each error during the three For total number of symptoms, maximum possible is 22. 20-second tests. The maximum total number of errors for any single con- For Symptom severity score, add all scores in table, maximum possible is 22 x 6 = 132. dition 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 4 should resume once subject is set. Subjects that are unable to maintain the testing SAC procedure for a minimum of five seconds at the start are assigned the highest Immediate Memory possible score, ten, for that testing condition. “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.” OPTION: For further assessment, the same 3 stances can be performed on a surface Trials 2 & 3: of medium density foam (e.g., approximately 50 cm x 40 cm x 6 cm). “I am going to repeat the same list again. Repeat back as many words as you can remember in 6,7 any order, even if you said the word before.“ Tandem Gait Complete all 3 trials regardless of score on trial 1 & 2. Read the words at a rate of one per second. Participants are instructed to stand with their feet together behind a starting line (the test is Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform best done with footwear removed). Then, they walk in a forward direction as quickly and as the athlete that delayed recall will be tested. accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the Concentration same gait. A total of 4 trials are done and the best time is retained. Athletes should complete Digits backward the test in 14 seconds. Athletes fail the test if they step off the line, have a separation between “I am going to read you a string of numbers and when I am done, you repeat them back to their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you not recorded and the trial repeated, if appropriate. would say 9-1-7.” 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. Coordination Examination Upper limb coordination Months in reverse order Finger-to-nose (FTN) task: “Now tell me the months of the year in reverse order. Start with the last month and go “I am going to test your coordination now. Please sit comfortably on the chair with your eyes backward. So you’ll say December, November … Go ahead” open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow 1 pt. for entire sequence correct and fingers extended), pointing in front of you. 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 Delayed Recall the nose, and then return to the starting position, as quickly and as accurately as possible.” The delayed recall should be performed after completion of the Balance and Coor- dination Examination. Scoring: 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 “Do you remember that list of words I read a few times earlier? Tell me as many words from the or do not perform five repetitions. Failure should be scored as 0. list as you can remember in any order.“ Score 1 pt. for each correct response References & Footnotes 1. This tool has been developed by a group of international experts at the 4th In- Balance Examination ternational Consensus meeting on Concussion in Sport held in Zurich, Switzerland Modified Balance Error Scoring System (BESS) testing 5 in November 2012. The full details of the conference outcomes and the authors of This balance testing is based on a modified version of the Balance Error Scoring the tool are published in The BJSM Injury Prevention and Health Protection, 2013, System (BESS)5. A stopwatch or watch with a second hand is required for this testing. Volume 47, Issue 5. The outcome paper will also be simultaneously co-published in other leading biomedical journals with the copyright held by the Concussion in Sport “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 Group, to allow unrestricted distribution, providing no alterations are made. twenty second tests with different stances.“ 2. McCrory P et al., Consensus Statement on Concussion in Sport – the 3rd Inter- national Conference on Concussion in Sport held in Zurich, November 2008. British (a) Double leg stance: Journal of Sports Medicine 2009; 43: i76-89. “The first stance is standing with your feet together with your hands on your hips and with 3. Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32 – 3. counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“ 4. McCrea M. Standardized mental status testing of acute concussion. Clinical Jour- nal of Sport Medicine. 2001; 11: 176 – 181. (b) Single leg stance: 5. Guskiewicz KM. Assessment of postural stability following sport-related concus- “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now sion. Current Sports Medicine Reports. 2003; 2: 24 – 30. 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 6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G. & McCrory, P. for 20 seconds with your hands on your hips and your eyes closed. I will be counting the Normative values for 16-37 year old subjects for three clinical measures of motor number of times you move out of this position. If you stumble out of this position, open your performance used in the assessment of sports concussions. Journal of Science and eyes and return to the start position and continue balancing. I will start timing when you are Medicine in Sport. 2010; 13(2): 196 – 201. set and have closed your eyes.“ 7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., Olsson, M., Yden. T. & Marshall, (c) Tandem stance: S.W. The effect of footwear and sports-surface on dynamic neurological screening in sport-related concussion. Journal of Science and Medicine in Sport. 2010; “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly 13(4): 382 – 386 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.”

Athlete Information Scoring Summary:

Any athlete suspected of having a concussion should be removed Test Domain Score from play, and then seek medical evaluation. Date: Date: Date:

Signs to watch for Number of Symptoms of 22 Problems could arise over the first 24 – 48 hours. The athlete should not be left alone Symptom Severity Score of 132 and must go to a hospital at once if they: Orientation of 5 -- Have a headache that gets worse Immediate Memory of 15 -- Are very drowsy or can’t be awakened -- Can’t recognize people or places Concentration of 5 -- Have repeated vomiting Delayed Recall of 5 -- Behave unusually or seem confused; are very irritable SAC Total -- Have seizures (arms and legs jerk uncontrollably) BESS (total errors) -- Have weak or numb arms or legs Tandem Gait (seconds) -- Are unsteady on their feet; have slurred speech Coordination of 1 Remember, it is better to be safe. Consult your doctor after a suspected concussion.

Return to play Notes: Athletes should not be returned to play the same day of injury. When returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, with stages of progression.

For example:

Rehabilitation stage Functional exercise at each stage Objective of each stage of rehabilitation

No activity Physical and cognitive rest Recovery

Light aerobic exercise Walking, swimming or stationary cycling Increase heart rate keeping intensity, 70 % maximum predicted heart rate. No resistance training Sport-specific exercise Skating drills in ice hockey, running drills in Add movement soccer. No head impact activities Non-contact Progression to more complex training drills, Exercise, coordination, and training drills eg passing drills in football and ice hockey. cognitive load May start progressive resistance training Full contact practice Following medical clearance participate in Restore confidence and assess normal training activities functional skills by coaching staff Return to play Normal game play

There should be at least 24 hours (or longer) for each stage and if symptoms recur the athlete should rest until they resolve once again and then resume the program at the previous asymptomatic stage. Resistance training should only be added in the later stages. If the athlete is symptomatic for more than 10 days, then consultation by a medical practitioner who is expert in the management of concussion, is recommended. Medical clearance should be given before return to play.

Concussion injury advice Patient’s name (To be given to the person monitoring the concussed athlete) Date / time of injury 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. Recovery Date / time of medical review time is variable across individuals and the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to Treating physician this timeframe. If you notice any change in behaviour, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please contact your doctor or the nearest hospital emergency department immediately.

Other important points: -- Rest (physically and mentally), including training or playing sports until symptoms resolve and you are medically cleared -- No alcohol -- No prescription or non-prescription drugs without medical supervision. Specifically: ·· No sleeping tablets ·· Do not use aspirin, anti-inflammatory medication or sedating pain killers -- Do not drive until medically cleared -- Do not train or play sport until medically cleared

Clinic phone number Contact details or stamp

Marist College Office of Sports Medicine: Post-Concussion/Mild Traumatic Brain Injury (MTBI) Take Home Instructions

Name: ______Date of Injury: ______Sport: ______Time of Injury: ______am/pm The athlete listed above has suffered a concussion/MTBI. At this time the athlete is alert, conscious and shows minimal to no signs and symptoms of a serious head injury but tragic results can still occur, leading to neurological deficits and even death. The effects of the injury depend on the amount of damage that the brain sustained and the signs and symptoms will vary with each injury. It is possible though for the athlete to appear normal following a blow to the head, but can later lapse into unconsciousness.

Signs and Symptoms of a Concussion/MTBI Checklist (check what student-athlete is experiencing):

___ HEADACHE ___ ALTERED EMOTION/BEHAVIOR ___ NECK PAIN ___ RINGING IN THE EARS ___ NAUSEA ___ FEELING SLOWED DOWN ___ VOMITING ___ FEELING IN A “FOG” ___ LOSS OF APPETITE ___ CONFUSION / DISORIENTATION ___ BALANCE PROBLEMS / DIZZINESS ___ BLURRED VISION ___ DROWSINESS / FATIGUE ___ SADNESS / ALTERED EMOTIONS ___ DIFFICULTY SLEEPING ___ CONTINUED DOUBLE VISION ___ SENSITIVITY TO LIGHT / NOISE ___ NERVOUSNESS / ANXIETY ___ DIFFICULTY CONCENTRATING ___ DIFFICULTY REMEMBERING

The following guidelines should be followed along with a member of the Sports Medicine Staff’s advice:

It is OK to: DO NOT: -Use ice pack for neck and head for comfort -Do any physical/strenuous activity -To walk to and attend class -Drive a vehicle -Go to sleep at a decent hour -Drink Alcohol/caffeinated beverages -Rest -Stay up late -Take aspirin/Ibuprofen (Advil/Motrin)/anti-inflammatory medication for headaches. -Watch TV, text, play video games, sit at a computer, or listen to loud music for long period of time.

A member of the Sports Medicine Staff may instruct a roommate to check you periodically for the above symptoms following a head injury. Do not take any medications unless you are instructed to do so by a member of the Sports Medicine Staff, Team Physician and/or Health Services Medical Staff.

Please remember to report back to the Sports Medicine Staff on ______for a follow up evaluation and testing. Please review the checked symptoms above. If these symptoms worsen, or if any of the additional symptoms appear report to the emergency room immediately.

EMERGENCY NUMBERS: Security: 575-5555 Health Services: 575-3270 Off-Campus Emergency: 911

Marist College Sports Medicine Staff: Jeffrey Carter 845-546-6646 (cell) Justin Giuliano 845-943-0246 (cell) Amanda Greco 917-535-1527 (cell) Briana Galeazzi 781-248-6784 (cell) Joelle Gage 845-399-2478 (cell)

Revised: September 24, 2015 Marist College Office of Sports Medicine: Graduated Return to Play (RTP) Protocol

This return to play protocol allows a gradual increase in volume and intensity during the recovery phase. The athlete is monitored for any concussion-like signs/symptoms during and after each exertional activity.

The following steps are not ALL to be performed on the same day. In some cases, steps 2 or 3 (or even 4) may be completed on the same day, but typically will occur over multiple days. Steps 4 and 5 will each be performed on separate and subsequent days.

No athlete can return to full activity or competitions until they are asymptomatic in limited, controlled, and full-contact activities, and cleared by the Marist College Sports Medicine Staff.

**If an athlete becomes symptomatic during any of the stages they must begin process from the beginning (stage 1) and progress at standardized pace.**

Rehabilitation Functional exercise at each stage Objective of each Stage of rehabilitation Stage

1. No Activity Symptom limited physical and Recovery cognitive rest

2. Moderate aerobic Stationary cycling keeping intensity <85% Increase heart rate and exercise maximum permitted heart rate; no blood pressure; ImPACT, resistance training (*see 20min workout) BESS and SCAT3 tested to compare to BL/Post

3. Sport-specific Running drills in soccer, football and basketball Add movement exercise Line drills in lacrosse

4. Non-contact Progression to more complex training drills Exercise, coordination training drills with no risk of contact; warm-up with team and cognitive load

5. Full-contact Following return to within 95% of baseline Restore confidence and practice and clearance; participate in normal training assess functional skills activities by coaching staff

6. Return to play Normal game day

Day #2 Aerobic Workout: Accommodations for Student-Athlete with MTBI/Concussion

Student-Athlete: ______Date of Evaluation: ______

Accommodations to classes Excused absences from classes --- student-athlete may return to classes on ______ No sport activities (varsity, club or intramural) until ______ Limited class attendance based on cognitive rigor Given rest periods throughout class period to control symptom levels Allowed to leave class if symptoms increase

Visual Stimulus Eat meals in an assigned area to avoid heightened dining hall noise and activity levels Permitted to wear sunglasses if sensitive to lights and/or television Provide student-athletes with outlines and class notes to avoid optical scanning requirements Provide notes scribed by a classmate or provided by instructor No smart boards/projector/computers/bright screens Limited computer/tablet use Enlarged font when possible

Auditory Stimulus Audible learning (discussions, reading out loud, text to speech programs if possible)

Workload/Multi-Tasking No hands on lab work that requires fine motor skills No homework Limited assignments to ___ minutes

Testing/Exams No testing/exams No testing/exams until up-to-date on course materials Exempt nonessential assignments/assessments Provide extended time to complete assignments/assessments Truncate length of tests/exams No more than one testing/exam session per day(Postponement and staggering of tests/exams during the recovery period) Allow for oral testing/exams (Read tests/exams/quizzes to the student-athlete during recovery period, if possible) Testing/Exams in quiet/isolated environment, when possible

Additional Recommendations/Comments Structure a plan for how the student-athlete will complete missed assignments and tests/exams Provided preferential seating Other: ______

Student-Athlete will be re-evaluated on ______

______Jeffrey Carter, Coordinator of Sports Medicine Alyssa Gates, Director of the Center for Student-Athlete Enhancement Revised: September 24, 2015

Marist College Office of Sports Medicine: Concussion/MTBI Return to Athletic Activity Acknowledgment

I acknowledge that I have sustained a concussion/MTBI. I understand that a concussion/MTBI 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 a 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/MTBI can happen even if you do not lose consciousness. I acknowledge that I have experienced signs and symptoms of a concussion/MTBI following my injury; however, all of my symptoms have fully resolved. I understand that concussion/MTBI symptoms may include:  Amnesia  Confusion  Headache  Loss of consciousness  Balance problems or dizziness  Double or fuzzy vision  Sensitivity to light and/or noise  Nausea (feeling that you might vomit)  Feeling sluggish, foggy or groggy  Feeling unusually irritable  Difficulty getting to sleep or disturbed sleep  Slowed reaction time  Concentration or memory problems (forgetting game plays, facts, meeting times, etc) I acknowledge that I have recovered from my concussion. I understand that my brain needs time to heal following an injury. I was held from athletic activity until I completely recovered. I understand that exercise or activities that involve increased 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 my brain is still healing, I am 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 member of the sports medicine staff, undergone concussion/MTBI 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/MTBI 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.

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Student‐Athlete Name (print) Student‐Athlete Signature Date

______Witness Name (print) Witness Signature Date