The injury commonly called a concussion is defined by the Centers for Disease Control and Prevention:
The term mild traumatic brain injury (MTBI) is used interchangeably with the term concussion. An MTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI).
MTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or even longer in some cases
It is the policy of the Berkshire School Athletic Training Department to recognize and treat sport related concussion according to the guidelines set forth by the NATA Position Statement: Managing Sport Related Concussion (Guskiewicz K, Bruce S, Cantu R, et al. NATA position statement: management of sport-related concussion. Journal of Athletic Training. 2004;39(3):280-297.) This policy has also been customized, where applicable, to the needs of this school in cooperation with the physicians at Macony Pediatrics. This policy will outline the steps to be taken when an athletic trainer has determined a student-athlete has a concussion.
According to Massachusetts state law a patient that is suspected of having any type of head injury is to be removed from play for the remainder of the game or practice and can only be allowed back to play after being evaluated by an allied health professional.
In the case of a head injury at Berkshire School the first step in the policy requires an evaluation of the patient with a suspected head injury by the staff athletic trainers or school nurse. If a patient is suspected of having a concussion the attending clinician will discuss the findings of the evaluation with a physician at Macony Pediatrics. The physician will decide the next course of action. If the student is to go to the emergency room and does not require an ambulance, the attending clinician will contact the on-duty emergency driver for transportation. The next step requires contact with the patient’s parents to relay information and communicate the physician’s directions.
When a patient is directed to wait until clinic to see a physician, the athletic trainer or school nurse will educate the patient and the patient’s parents about danger signs to look for and the recommended treatment. During that conversation the patient will be instructed to not participate in any type of physical activity more intense than walking. The patient will be restricted from sports practices, games, dramatic performances, musical performances, dance performances, guided hikes, rock climbing, and any other Berkshire School event deemed inappropriate for the patient.
At the patient’s clinic appointment a staff athletic trainer will be present to provide background information to the physician and to help make decisions for the rest of the treatment plan. The goals of this appointment are to determine what the extent of the injury is and determine the next course of action.
All Berkshire School students are required to perform a Baseline test using the ImPACT neurocognitive assessment software. A post-injury administration of the ImPACT test will be conducted at an appropriate stage of the recovery process; this is usually done once the patient reports being asymptomatic. This information will be used as a piece of the information puzzle in determining severity of injury and return to play readiness.
Return to Play Criteria
When a patient has been cleared to progress back into full athletic participation Berkshire School athletic trainers will oversee a step-wise progressive return. Following a successful completion of the progressive return the athletic trainers will clear the patient for participation and submit a completed form to the physician. The outline of this progression is as follows:
•The patient, once released into the care of the athletic trainers and is no longer required to see a physician, will check in daily at the athletic training facility. At that check-in signs and symptoms will be reported.
•Once the patient has been symptom free for 24+ hours (or more as instructed by physician) an ImPACT test will be administered. When the ImPACT results meet or exceed Baseline standards the patient will move into the next phase. Exceptions to this guideline vary based on individual patient needs and will be determined by physician and athletic trainer.
•The next phase is a cardiovascular challenge usually to be administered as a 10 minute stationary bike ride under supervision. If the patient does not experience a recurrence of symptoms the next phase is conducted.
•After the initial CV challenge the next phase is to have the patient perform sport-specific activities that do not place the patient at risk for concussion. This is usually performed as a half or full length non-contact practice.
•The final phase is reached when the patient has completed all previous phases with no recurrence of symptoms. At this point the patient will participate in a full practice with contact. At the end of that practice the patient will complete a final administration of the ImPACT test. If the results meet or exceed Baseline standards while fatigued the patient will be given final clearance to return to full participation without restrictions.
•An important note: if, at any time during or following one of these phases, the patient experiences any recurrence of symptoms the patient will be removed from athletic participation until symptom free for 24 hours. At that point the patient will be able to resume the return to play progression at the previous step at which no symptoms were experienced. If a patient experiences two set-backs of this nature in relation to the same injury a new plan of action, possibly including a neurologist visit, will be discussed by the health care team.
Please see www.mass.gov/dph/sportsconcussion for MA law regarding concussions, treatment, and return to play criteria. Be advised that MA law at this time applies to MIAA member schools and not to independent schools and that Berkshire strives to be above board in this matter for the safety our students.
Heat Illness Policy: In the event of a heat related injury/illness (exertional heat stroke, heat exhaustion, heat cramps, and exertional hyponatremia) the policy of the athletic training department is to provide medical care that is based on the NATA Position Statement on Exertional Heat Illness and the Inter-Association Task Force Consensus Statement on Heat Illness. (Binkley H, Beckett J, Casa D, Kleiner D, Plummer P. NATA position statement: exertional heat illnesses. Journal of Athletic Training. 2002;37(3):329-343)( http://www.nata.org/sites/default/files/inter-association-task-force-exertional-heat-illness.pdf)
The athletic training staff at Berkshire School has a heat index monitor that is a handheld, digital device. This machine gives the athletic training staff the temperature and the relative humidity. The device gives these readings and scores them on a scale that ranges from cold to extreme danger. It is the policy of this facility to follow the NATA recommendations for action steps corresponding to the danger scale. Those steps are as follows:
Level of Risk
Risk low but still exists on the basis of risk factors
Risk level increases as event progresses through the day
Everyone should be aware of injury potential; individuals at risk should not compete
Consider rescheduling or delaying the event until safer
conditions prevail; if the event must take place, be on high alert
Events will be cancelled until conditions improve
The following procedures are recommended if dehydration is suspected:
•Dehydrated athletes should move to a cool environment and rehydrate.
•Athletes should begin exercise sessions properly hydrated. Any fluid deficits should be replaced within 1 to 2 hours after exercise is complete.
•Given the nature of sweat and variability and timing of nutritional intake, hydrating with a sports drink containing carbohydrates and electrolytes (i.e., sodium and potassium) before and during exercise is optimal to replace losses and provide energy. Because athletes replace only about half of the fluid lost when drinking water, a flavored sports drink may promote an increase in the quantity of fluids consumed.
•Replacing lost sodium after exercise is best achieved by consuming food in combination with a rehydration beverage.
•Athletes should have convenient access to fluids throughout practice and be allowed to hydrate in addition to prescribed breaks. These factors can minimize dehydration and may maximize performance.
•A nauseated or vomiting athlete should seek medical attention to replace fluids via an intravenous line.
If the degree of dehydration is minor and the athlete is symptom free, continued participation is acceptable. The athlete must maintain hydration status and should receive periodic checks from onsite medical personnel.
EXERTIONAL HEAT STROKE (EHS)
Aggressive and immediate whole-body cooling is the key to optimizing treatment:
The duration and degree of hyperthermia may determine adverse outcomes. If untreated, hyperthermia-induced physiological changes resulting in fatal consequences may occur within vital organ systems (e.g., muscle, heart, brain, liver, kidneys, etc.). Due to superior cooling rates, immediate whole-body cooling via cold water immersion is the best treatment for EHS and should be initiated within minutes post-incident. Provided that adequate emergency medical care is available onsite (i.e., ATC, EMT or physician), it is recommended to cool first via cold water immersion, then transport second. Cooling can be successfully verified by measuring rectal or oral temperature. If onsite rapid cooling via cold water immersion is not an option or if other complications develop that would be considered life threatening (i.e., airway, breathing, circulation), immediate transport to the nearest medical facility is essential.
The following procedures are recommended if EHS is suspected:
•Immediately immerse athlete in tub of cold water (approximately 35°-58°F/1.67°-14.5°C), onsite if possible. Remove clothing/equipment. (Immersion therapy should include constant monitoring of core temperature by rectal thermistor [or oral thermometer].)
•If immersion is not possible, transport immediately.
•Alternative cooling strategies should be implemented while waiting for and during transport. These strategies could include: spraying the body with cold water, fans, ice bags or ice over as much of the body as possible and/or cold towels (replace towels frequently).
•Monitor airway, breathing, circulation, core temperature, and CNS status (cognitive, convulsions, orientation, consciousness, etc.) at all times.
•Cease aggressive cooling when core temperature reaches approximately 101°-102°F (38.3°-38.9°C); continue to monitor.
•If rapid onsite cooling was administered and rectal temperature has reached approximately 101°-102°F (38.3°-38.9°C), transport athlete to medical facility for monitoring of possible organ system damage.
Physiological changes may occur after an episode of EHS. For example, the athlete's heat tolerance may be temporarily or permanently compromised. To ensure a safe return to full participation, a careful return-to-play strategy should be decided by the athlete's physician and implemented with the assistance of the ATC or other qualified health care professional.
The following guidelines are recommended for return-to-play after EHS:
•Physician clearance is necessary before returning to exercise. The athlete should avoid all exercise until completely asymptomatic and all laboratory tests are normal.
•Severity of the incident should dictate the length of recovery time.
•The athlete should avoid exercise for the minimum of 1 week after release from medical care.
•The athlete should cautiously begin a gradual return to physical activity to regain peak fitness and acclimatization under the supervision of an ATC or other qualified health care professional. Type and length of exercise should be determined by the athlete's physician and might follow this pattern:
1. Easy-to-moderate exercise in a climate controlled environment for several days, followed by strenuous exercise in a climate-controlled environment for several days.
2. Easy-to-moderate exercise in heat for several days, followed by strenuous exercise in heat for several days.
3. (If applicable) Easy-to-moderate exercise in heat with equipment for several days, followed by strenuous exercise in heat with equipment for several days.
The following procedures are recommended if heat exhaustion is suspected:
•Remove athlete from play and immediately move to a shaded or air-conditioned area.
•Remove excess clothing and equipment.
•Cool athlete until rectal temperature is approximately 101°F (38.3°C).
•Have athlete lie comfortably with legs propped above heart level.
•If athlete is not nauseated, vomiting or experiencing any CNS dysfunction, rehydrate orally with chilled water or sports drink. If athlete is unable to take oral fluids, implement intravenous infusion of normal saline.
•Monitor heart rate, blood pressure, respiratory rate, rectal temperature and CNS status.
•Transport to an emergency facility if rapid improvement is not noted with prescribed treatment.
The following guidelines are recommended for return-to-play after heat exhaustion:
•Athlete should be symptom free and fully hydrated.
•Recommend physician clearance or, at minimum, a discussion with supervising physician before return.
•Rule out underlying condition or illness that predisposed athlete for continued problems.
•Avoid intense practice in heat until at least the next day to ensure recovery from fatigue and dehydration. (In severe cases, intense practice in heat should be delayed for more than 1 day.)
•If underlying cause was lack of acclimatization and/or fitness level, correct this problem before athlete returns to full-intensity training in heat (especially in sports with equipment).
The following procedures are recommended if heat cramps are suspected:
•Re-establish normal hydration status and replace some sodium losses with a sports drink or other sodium source.
•Some additional sodium may be needed (especially in those with a history of heat cramps) earlier in the activity (pre-cramps) and is best administered by dilution into a sports drink. For example, 1/2 g of sodium (equal to the amount of sodium found in 1/4 tsp of table salt) dissolved in about 1 L (approximately 32 oz) of a sports drink early in the exercise session provides ample fluids and sodium, and the flavor (while certainly saltier) is still very palatable.
•Light stretching, relaxation and massage of the involved muscle may help acute pain of a muscle cramp.
Athletes should be assessed to determine if they can perform at the level needed for successful participation. After an acute episode, diet, rehydration practices, electrolyte consumption, fitness status, level of acclimatization and use of dietary supplements should be reviewed and possibly modified to decrease risk of recurring heat cramps.
The following procedures are recommended if exertional hyponatremia is suspected:
•If blood sodium levels cannot be determined onsite, hold off on rehydrating athlete (may worsen condition) and transport immediately to a medical facility.
•The delivery of sodium, certain diuretics or intravenous solutions may be necessary. All will be monitored in the emergency department to ensure no complications develop.
The following guidelines are recommended for return-to-play after exertional hyponatremia:
•Physician clearance is strongly recommended in all cases.
•In mild cases, activity can resume a few days after completing an educational session on establishing an individual-specific hydration protocol. This will ensure the proper amount and type of beverages and meals are consumed before, during and after physical activity.