IRB CONCUSSION GUIDELINES. Non Approved Healthcare Professionals and General Public

Transcription

1 GUIDELINE SUMMARY RECOGNISE AND REMOVE - learn t recgnise the signs and symptms f cncussin and remve a player frm the field if ANY dubt PROTECT OUR YOUNG ATHLETES - The IRB recmmends different return t play prtcls fr different ages Cncussin must be taken extremely seriusly t safeguard the lng term welfare f players. All players with a diagnsed cncussin must be remved frm the field f play and nt return t play r train n the same day. Players with a diagnsed cncussin must g thrugh a graduated return t play prgram (GRTP), described later in this dcument. All players with a suspected cncussin where n apprpriately trained persnnel are present must be assumed t have a diagnsed cncussin and must be remved frm the field f play and nt return t play r train n the same day. In this situatin, players must g thrugh a graduated return t play (GRTP) prtcl. Fr elite cmpetitins, where apprved by the IRB s Chief Medical Officer and Head f Technical Services, players with a head injury where the diagnsis is nt immediately apparent must be remved frm play and can be assessed by a certified medical prfessinal (CMP - defined as "A Certified Medical Prfessinal wh has successfully cmpleted the IRB n line educatin prgramme fr Match Day Medical Staff") assisted by the Pitch Side Cncussin Assessment (PSCA) Tl. Players wh cmplete a GRTP must receive medical clearance frm a dctr r an apprved healthcare prfessinal (as defined by each Unin) befre returning t play The IRB recgnises that there is cnsiderable diversity in health care supprt acrss and within each Member Unin. Because f this diversity each Unin is encuraged t identify the rles and respnsibilities f medical and healthcare practitiners and t establish a definitin f apprved healthcare prfessinal relevant t their respective jurisdictins. Each Unin will be respnsible fr cnfirming wh is apprved t diagnse cncussin, prvide a clearance t start a GRTP, mnitr a GRTP and prvide a clearance t return t play. Intrductin The IRB takes player welfare seriusly and has been a primary supprter f the 2008 and 2012 Zurich Cncussin in Sprt Cnsensus Meetings. These meetings bring tgether the wrld experts in cncussin every fur years t review the current evidence surrunding cncussin. Fllwing a Cnsensus Cnference, a psitin paper (Cnsensus Statement) is develped summarizing the current evidence based n knwledge in the area f cncussin. This 2013 IRB Cncussin Guideline has been updated t reflect the principles agreed at the Zurich 2012 Cncussin Cnsensus Cnference. These IRB guidelines are designed t be used by nn apprved healthcare prfessinals, team management, teachers, parents, referees and players. The guidelines are meant t ensure that players wh suffer cncussin are managed effectively t prtect their lng term health and welfare. Scientific knwledge in the field f cncussin is cnstantly evlving and

2 the cnsensus prcess and scientific meetings will make sure that the IRB guidelines keep pace with these changes. Separate guidelines are available fr medical practitiners and apprved healthcare prfessinals. What is Cncussin? Cncussin is a brain injury caused by either direct r indirect frces t the head. Cncussin typically results in the rapid nset f shrt-lived impairment f brain functin ¹. Lss f cnsciusness ccurs in less than 15% f cncussin cases and whilst a feature f cncussin, lss f cnsciusness is nt a requirement fr diagnsing cncussin. Cncussin results in a disturbance f brain functin (e.g. memry disturbance, balance prblems r symptms) rather than damage t structures such bld vessels, brain tissue r fractured skull. Typically standard neur-imaging such as MRI r CT scan is nrmal. CONCUSSION MUST BE TAKEN EXTREMELY SERIOUSLY. Head Injuries, Cncussin and Structural Brain Injuries Cncussin is nly ne diagnsis that may result frm a head injury. Head injuries may result in ne r mre f the fllwing: 1. Superficial injuries t scalp r face such as laceratins and abrasins 2. Subcncussive event a head impact event that des nt cause a cncussin 3. Cncussin - an injury resulting in a disturbance f brain functin 4. Structural brain injury - an injury resulting in damage t a brain structure fr example fractured skull r a bleed int r arund the brain Structural brain injuries may present mimicking a cncussin. In this instance the signs and symptms f a structural brain injury will usually persist r deterirate ver time eg persistent r wrsening headache, increased drwsiness, persistent vmiting, increasing cnfusin and seizures. Medical assessment f a cncussin r a head injury where the diagnsis is nt apparent is recmmended t exclude a ptential structural brain injury. All head injuries shuld be cnsidered assciated with cervical spine injury until prven therwise Different Ages It is accepted practice that children and adlescent athletes (< 19 years ld) with cncussin shuld be managed mre cnservatively. This is supprted by evidence that cnfirms that children: 1. are mre susceptible t cncussin 2. take lnger t recver 3. have mre significant memry and mental prcessing issues. 4. are mre susceptible t rare and dangerus neurlgical cmplicatins, including death caused by a secnd impact syndrme (athletes under 19 years) The IRB supprts a mre cnservative management f cncussin fr children and adlescent and has develped age specific return t play prtcls fr these grups (details f these return t play prtcls are utlined later in this dcument)

3 DIAGNOSIS AND ASSESSMENT OF CONCUSSION Identifying cncussin The IRB supprts and prmtes RECOGNISE and REMOVE. The Pcket Cncussin Recgnitin Tl (Appendix 1) develped by the Zurich 2012 Cncussin Cnsensus Grup supprts this Recgnise and Remve message and is suitable fr use in Aged Grade and Cmmunity Rugby. This Tl highlights the signs and symptms suggestive f a cncussin. They include: Visible clues f ptential cncussin - What yu see Any ne r mre f the fllwing visual clues can indicate a pssible cncussin: Dazed, blank r vacant lk Lying mtinless n grund / Slw t get up Unsteady n feet / Balance prblems r falling ver / Inc-rdinatin Lss f cnsciusness r respnsiveness Cnfused / Nt aware f plays r events Grabbing / Clutching f head Cnvulsin Mre emtinal / Irritable Symptms f ptential cncussin - What yu are tld Presence f any ne r mre f the fllwing signs & symptms may suggest a cncussin: Headache Dizziness Mental cluding, cnfusin, r feeling slwed dwn Visual prblems Visual prblems Nausea r vmiting Fatigue Drwsiness / Feeling like in a fg / difficulty cncentrating Pressure in head Sensitivity t light r nise Questins t ask - What questins t ask Failure t answer any f these questins crrectly may suggest a cncussin. What venue are we at tday? Which half is it nw? Wh scred last in this game? What team did yu play last week / game? Did yur team win the last game? If a Player is has signs r symptms f a pssible cncussin that player must be RECOGNISE AND REMOVE and IF IN DOUBT, SIT THEM OUT.

4 On field r pitch side management A Player with a signs r symptms f cncussin must be remved in a safe manner in accrdance with emergency management prcedures and medically assessed. If a cervical spine injury is suspected the Player shuld nly be remved by emergency healthcare prfessinals with apprpriate spinal care training. Team mates, caches, match fficials, team managers, administratrs r parents wh bserve an injured player displaying any f the signs r symptms after an injury event with the ptential t cause a cncussin MUST d their best t ensure that the player is remved frm the field f play in a safe manner. In elite cmpetitins where apprval has been given by the IRB s Chief Medical Officer and Head f Technical Services and where a Certified Medical Practitiner (CMP) is present, a pitch side assessment (PSCA) may be undertaken. The PSCA has been develped t prvide experienced Team Dctrs with extra time t assess a player wh has a head injury where the diagnsis is nt immediately apparent. The PSCA has NOT been develped fr the Cmmunity Game. Diagnsing cncussin The Zurich 2012 Cncussin Cnsensus Statement, recgnised as the best practice dcument fr cncussin management, identifies cncussin as being amng the mst cmplex injuries in sprts medicine t diagnse, assess and manage¹. This paper als cnfirms that there is n perfect diagnstic test r marker fr the immediate diagnsis f cncussin in the sprting envirnment¹. The 2012 Zurich Statement als cnfirmed that clinical diagnsis by a dctr remains the gld standard and this diagnsis shuld be supprted by: a review f symptms using a standardised checklist cgnitive (memry) assessment and balance evaluatin SCAT 3 (Appendix 2) develped by the Cncussin in Sprts Grup¹ is an assessment tl that tests fr symptms, memry and balance. The SCAT 3 Tl supprts the dctr r apprved healthcare prfessinal t make a diagnsis and is nt a stand-alne methd t diagnse cncussin, measure recvery r make decisins abut an athlete s readiness t return t cmpetitin after cncussin. Within the SCAT 3 dcument it is highlighted that "an athlete may have a cncussin even if their SCAT 3 is nrmal." Ideally a pst injury SCAT 3 shuld be cmpared with a baseline SCAT 3. In the absence f the baseline SCAT 3 fr adults, the IRB has identified reference range baseline data fr Rugby players. If n baseline is available the fllwing shuld be cnsidered strngly in favur as supprting a diagnsis f cncussin: Symptm checklist - ne r mre symptms declared in the symptm list which is nt usually experienced by the player fllwing a Rugby match r training OR Balance evaluatin - Tandem test - 3 r mre errrs r single leg stance test - 4 r mre errrs OR SAC assessment

5 - Ttal SAC scre 24 r belw - Cncentratin scre (digits backward) 2 r belw - Delayed recall 3 r less wrds Players with baseline assessments belw the abve scres shuld be scrutinized t cnfirm that the baseline testing has nt been manipulated by the player. The IRB recmmends the utilizatin f SCAT 3 fr all players 13 years and lder if practical. A child SCAT 3 (Appendix 3) is nw available fr players under 13 years f age. In summary the diagnsis f cncussin is a clinical diagnsis supprted by a tl such as SCAT 3. Decisins regarding cncussin shuld nt be based slely n the results f any supprt tl and remain a clinical decisin fr dctrs. Onset f Symptms It shuld be nted that the signs and symptms f cncussin can present at any time but typically becme evident in the first hurs fllwing a head injury. Recvery frm Cncussin Recvery frm cncussin is spntaneus and typically fllws a sequential curse. The majrity (80 90%) f cncussins reslve in a shrt (7 10 day) perid, althugh the recvery time frame may be lnger in children and adlescents. Players must be encuraged nt t ignre symptms at the time f injury and must nt return t play prir t the full recvery fllwing a diagnsed cncussin. The risks assciated with premature return t play include: a) a secnd cncussin due t increased risk b) an increase risk f ther injuries because f pr decisin making r reduced reactin time assciated with a cncussin c) reduced perfrmance d) serius injury r death due t an unidentified structural brain injury e) a ptential increased risk f develping lng term neurlgical deteriratin Cmprehensive medical assessment and fllw up is required until a cncussin has fully reslved. Players must be hnest with themselves and medical staff fr their wn prtectin. The IRB recgnizes the heightened risk f head injury and cncussin and its cmplicatins in children and adlescent (less than 19 years f age) players. Extra cautin must be taken t prevent such players returning t play r cntinuing playing r training if any suspicin f cncussin exists. A secnd head impact in a player wh has nt fully recvered frm cncussin culd lead t dangerus neurlgical cmplicatins, including death. MANAGEMENT OF CONCUSSION Remval frm Play All players with a diagnsed cncussin must be remved frm the field f play and nt return t play r train n the same day. Players with a diagnsed cncussin must g thrugh a graduated return t play prtcl (GRTP).

6 All nn elite players with a ptential cncussin must be presumed t have a diagnsed cncussin and must be remved frm the field f play and nt return t play r train n the same day. Nn elite players with a ptential cncussin must g thrugh a graduated return t play prtcl (GRTP). Elite players where the diagnsis is unclear may be assessed pitch side if playing in IRB apprved cmpetitins and supprted by a Certified Medical Practitiner (CMP). Graduated Return t Play All players diagnsed with a cncussin must g thrugh a graduated return t play (GRTP) prgram as utlined in this dcument. All nn elite players with a ptential cncussin must g thrugh a graduated return t play (GRTP) prgram. The IRB acknwledges, as per Zurich 2012, that yunger athletes wh sustain a cncussin shuld be managed mre cnservatively. The IRB recmmends different minimum rest perids and different length GRTP stages fr differing age grups - prtecting ur yung athletes. These recmmendatins are utlined the IRB Age Specific Cncussin Return t Play Prtcls (Appendix 4). A summary f the minimum rest perids and different length GRTP stages fr different ages is shwn belw U/6 - U/15 - minimum rest perid 2 weeks and symptm free fllwed by a GRTP with each stage lasting 48 hurs (Play - Day 23 pst injury) U/16 - U/19 - minimum rest perid 1 week and symptm free fllwed by a GRTP with each stage lasting 24 hurs (Play - Day 12 pst injury) Adult - minimum rest perid 24 hurs free f symptm fllwed by a GRTP with each stage lasting 24 hurs (Play - Day 6 pst injury) A GRTP shuld nly cmmence if the player has cmpleted the minimum rest perid fr their age is symptm free and ff medicatin that mdifies symptms f cncussin. Medical r apprved healthcare prfessinal clearance is required prir t cmmencing a GRTP. The management f a GRTP shuld be undertaken n a case by case basis and with the full cperatin f the player. The cmmencement f the GRTP will be dependent n the time in which symptms are reslved and the age f the player. It is imprtant that cncussin is managed s that there is physical and cgnitive rest (avidance f activities requiring sustained cncentratin) until there are n remaining symptms fr a minimum f 24 cnsecutive hurs withut medicatin that may mask the symptms. In the early pst injury perid rest is defined as cmplete physical and cgnitive rest hwever if recvery is delayed rest is defined as being activity belw the level at which physical activity r cgnitive activity prvkes symptms.

7 Figure 1: Cncussin Management Flwchart fr Elite and Cmmunity Rugby The Graduated Return t Play Prgram Befre a Player can restart exercise they must have rested fr the prescribed minimum rest perid AND be symptm free. The GRTP Prgram cntains six distinct stages. The first stage is the recmmended rest perid fr the athlete's age. The next fur stages are training based restricted activity Stage 6 is a return t play Under the GRTP Prgram, the Player can prceed t the next stage if n symptms f cncussin (SCAT 3 prvides the symptm checklist) are shwn at the current stage (that is, bth the perids f rest and exercise during that 24-hur perid). If any symptms ccur while prgressing thrugh the GRTP prtcl (Figure 2), the player must return t the previus stage and attempt t prgress again after a minimum 24-hur perid f rest has passed withut the appearance f any symptms. Prir t entering Stage 5, a Medical Practitiner r apprved healthcare prfessinal and the Player must first cnfirm that the player can take part in this stage. Full cntact practice equates t return t play fr the purpses f cncussin. Hwever return t play itself shall nt ccur until Stage 6 (Table 3). The GRTP applies t all situatins including 'multiple game-same day' turnaments.

8 Table 3: GRTP Prtcl Stage Rehabilitatin Stage Rest as per minimum 1 rest perid prescribed fr player's age 2 Light aerbic exercise 3 Sprt-specific exercise 4 Nn-cntact training drills Exercise Allwed Cmplete physical and cgnitive rest withut symptms Walking, swimming r statinary cycling keeping intensity, <70% maximum predicted heart rate. N resistance training. Symptm free during full 24-hur perid. Running drills. N head impact activities. Prgressin t mre cmplex training drills, e.g. passing drills. May start prgressive resistance training. Objective Recvery Increase heart rate Add mvement Exercise, crdinatin, and cgnitive lad 5 Full Cntact Practice Nrmal training activities Restre cnfidence and assess functinal skills by caching staff 6 Return t Play Player rehabilitated Recver GRTP managed by a medical practitiner r apprved healthcare prfessinal (HCP) Fr GRTP prgrams managed by a medical practitiner r an apprved HCP, the bservatin f prgress may be delegated t a healthcare prfessinal while the management f the prgram must remain the respnsibility f the medical practitiner. Adlescents and children, 19 years and under, MUST NOT return t play withut clearance frm a medical practitiner r apprved healthcare practitiner. GRTP where n medical r apprved healthcare prfessinal practitiner is available When a medical practitiner r apprved healthcare practitiner is nt available t manage and review the GRTP, the player MUST NOT play until cmpletin f a minimum 2 week rest perid and the relevant GRTP fr that age. In additin the prcess shuld be bserved and managed by smene familiar with the player wh culd identify any abnrmal signs displayed by the player. Clearance t play by a medical practitiner r apprved healthcare practitiner shuld always be sught. Hwever, there may be ccasins (which will be in extreme and rare situatins) where a player cannt access a medical practitiner r apprved healthcare practitiner t assess the player and clear them t resume full cntact practice. In these circumstances, the Unin having jurisdictin ver the player must put in place prcesses and mechanisms which nly permit players t resume full cntact practice when it is safe t d s. These prcesses and mechanisms will vary frm Unin t Unin. GRTP cnclusin It is recgnised that players will want t return t play as sn as pssible fllwing a cncussin. Players, caches, management, parents and teachers must exercise cautin t ensure that: all symptms have subsided fully; the GRTP prgram is fllwed; and the advice f medical practitiners r apprved healthcare practitiner is strictly adhered t.

9 In ding s, all cncerned can reduce the risk t a player s career lngevity and lng term health. Figure 2: Cncussin GRTP Prtcls fr different levels f the game As identified in the last clumn f Figure 2, if n medical practitiner is available t manage a Graduated Return t Play (GRTP), irrespective f their age, the player MUST rest fr a minimum f 2 weeks and be symptm free. At the cmpletin f this 2 week rest perid if the player is symptm free they can cmmence the GRTP with each stage prgressing each 24 r 48 hurs depending n the age f the player. All invlved in the prcess f cncussin management must be vigilant fr the return f symptms r the pssible develpment f psychlgical issues after a cncussive event. If symptms re-ccur the player must cnsult a medical practitiner r apprved healthcare practitiner. Thse invlved in the prcess f cncussin management and/r aware f the return f symptms shuld d all they can t ensure that the player cnsults a medical practitiner r apprved healthcare practitiner as sn as pssible. Recurrent r difficult cncussins Fllwing a cncussin a player is at an increased risk f a secnd cncussin within the next 12 mnths. The IRB recmmends that all cncussins be taken seriusly and that full recvery be achieved prir t re-intrductin f exercise. Players with: a secnd cncussin within 12 mnth

10 a histry f multiple cncussins unusual presentatins r prlnged recvery shuld be assessed and managed by health care prviders (multidisciplinary) with experience in sprts-related cncussins. If a medical practitiner experienced in cncussin management r Unin apprved healthcare prvider is unavailable the player with a recurrent r difficult cncussin histry shuld be managed using the GRTP prtcl frm the lwer age grup as a minimum. It is recmmended that each Unin identify a cre list f specialists t deal with cmplex cncussins Factrs impacting n the diagnsis and management f cncussin The factrs listed belw may predict the ptential fr prlnged r persistent symptms. Players with these factrs shuld be carefully mnitred by experienced practitiners. Table 2 Factrs Symptms Signs Sequelae Tempral Threshld Age C- and premrbidities Medicatin Behaviur Sprt Exacerbating factrs Number f cncussins suffered histrically Duratin f current cncussin symptms (>10 days) Severity f current cncussin Prlnged lss f cnsciusness (>1 minute) Amnesia Cncussive cnvulsins Frequency repeated cncussins ver time Timing injuries clse tgether in time Recency recent cncussin r traumatic brain injury Repeated cncussins ccurring with prgressively less impact frce r slwer recvery after each successive cncussin Child (<10 years) and adlescent (10-18 years) Migraine, depressin r ther mental health disrders, attentin deficit hyperactivity disrder (ADHD), learning disabilities, sleep disrders Psychactive drugs, anticagulants Dangerus style f play High risk activity, cntact and cllisin sprt, high sprting level Cnclusin The IRB recmmends that the Gld Standard cncussin management be implemented fr all players diagnsed with a cncussin r when a player is suspected f having a cncussin during a game r training at which there is n apprved health care prfessinal present. This Gld Standard includes: Assessment by a certified medical practitiner familiar with internatinal cncussin prtcls; Thrugh, serial symptm analysis; General and neurlgical examinatin; Balance assessment; and Assessment f cgnitive functin preferably cmpared t a pre-injury baseline.

11 IRB CONCUSSION MANAGEMENT - 6 Rs Recgnise Learn the signs and symptms f a cncussin s yu understand when an athlete might have a ptential cncussin (see the Cncussin Recgnitin Tl fr mre details) Remve If an athlete has a cncussin r even a ptential cncussin he r she must be remved frm play immediately Refer Once remved frm play, the player shuld be referred immediately t a medical practitiner r qualified healthcare prfessinal wh is trained in evaluating and treating cncussins Rest Players must rest frm exercise until symptm-free and then start a Graduated Return t Play prgram. The IRB recmmends minimum rest perids fr different ages - U/6 t U/15-2 weeks minimum rest, U/16-U/19-1 week minimum rest, Adults - 24 hurs minimum rest Recver Full recvery frm the cncussin is required befre return t play is authrized. This includes being symptm-free. Rest and specific treatment ptins are critical fr the health f the injured participant Return In rder fr safe return t play in Rugby, the athlete must be symptm-free and cleared in writing by a medical practitiner r apprved healthcare prfessinal wh is trained in evaluating and treating cncussins. The athlete must cmplete a GRTP (Graduated Return t Play) prgram. REFERENCES 1. McCrry P, Meeuwisse WH, Aubry M et al. Cnsensus statement n cncussin in sprt: the 4th Internatinal Cnference n Cncussin in Sprt held in Zurich, Nvember Br J Sprts Med 2013;47: Putukian M, Raftery M, Guskiewicz K, et al. On field assessment f cncussin in the adult athlete. Br J Sprts Med 2013;47: The IRB recgnises that the science f cncussin is evlving. The IRB is actively invlved in research and mnitring f the scientific develpments and will endeavur t update these guidelines peridically as scientific evidence emerges hwever all users f these Guidelines are advised t check with a medical practitiner r apprved healthcare prfessinal shuld they have any cncerns r queries with respect t cncussin, these Guidelines and/r scientific develpments in this field.