MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION EVALUATION & RETURN TO PLAY GUIDELINES
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Updated 6-9-15
MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION
EVALUATION & RETURN TO PLAY GUIDELINES
The University of Mississippi Sports Medicine staff will serially evaluate student-athletes with
suspected mild traumatic brain injury/concussions by the following protocol developed for the use of
University of Mississippi Sports Medicine Staff.
Pre-Season Education-student athletes will receive a concussion fact sheet and a responsibility
to report document with their medical packet which must be signed and dated. Athletic trainers and
team physicians will review concussion policies yearly and acknowledge in a signed document.
Coaches and directors of athletics will review the concussion policy at the initial yearly coaches
meeting. If coaches are not present at that meeting then it is the responsibility of the athletic trainer of
the sport to present it to those coaches by sport. There should be a signed document that states they
have reviewed the policy.
Baseline Testing-
ALL ATHLETES WILL COMPLETE an initial screening as part of their PPE which will
include history of prior concussions and symptoms. In addition, the following tests will be
performed during/close as possible to the PPE to be used as baseline results:
• ImPACT – Neuropsychological Assessment
• Balance Error Scoring System (BESS modified for eyes closed on floor only)
• Once these tests have been completed the team physician will review them and clear the
student athlete for participation.
Time of Injury-
A. Any student-athlete that exhibits signs, symptoms, or behaviors consistent with a concussive injury
(listed below) during practice or competition will be withheld from athletic participation for the
remainder of that day. Some possible signs or symptoms may include, but not limited to:
a. Altered level and/or loss of consciousness;
b. Confusion, as evidenced by disorientation to person, time, or place; inability to respond
appropriately to questions; inability to process information correctly and/or respond
appropriately to analytical questions; or inability to remember assignments and/or plays;
c. Amnesia (antegrade and/or retrograde; immediate or delayed);
d. Abnormal neurological examination (ex: abnormal papillary response, persistent
dizziness/vertigo, abnormal balance, etc);
e. New and persistent headache, particularly if accompanied by photosensitivity or other
visual disturbances, tinnitus, nausea, vomiting, or dizziness;
f. Any other persistent signs or symptoms of a concussive injury.
B. These student athletes that are suspected of suffering a MTBI/concussion will be evaluated by an ATC
or a physician that has had experience with assessing concussions:
a. SCAT3 Evaluation Sheet (within the first 24 hours if possible)
b. Physician evaluation and examination (if applicable)
Upon evaluation if any of the following signs/symptoms are present, the Emergency Action Plan must
be followed, including transportation for further medical care.
Glasgow Coma Scale
Step 3 Return to Full Sport Participation-
If the student-athlete progresses through all 3 stages of Step 2 and continues to be completely
asymptomatic, the student-athlete will be referred to the team physician or his/her designee for
evaluation and consideration for return to full sport activity. Once team physician has cleared the
student-athlete to return to full sport activity, they will have at least one session of activity in a practice
setting before returning to full game activity. If student-athlete completes full practice session,
including contact activity if applicable, they will be considered cleared to return to full game and sport
participation. It will be noted that student-athlete will still need to be cognizant of any symptoms and
report those to their ATC going forward.
Return to Learn
It is recognized that during the initial period of recovery, the student-athlete should engage in
physical AND cognitive rest until such time that he/she is asymptomatic. No student-athlete
will engage in classroom activity as the same day as a concussion, and may remain at
home/dorm as needed. It shall be at the discretion of the University of Mississippi Sports
Medicine Staff to recommend removal of student-athlete from any activities that increase
concussive symptoms (ie: reading, classroom work, taking tests, sport-specific meetings, etc)
as per Inter-Association Consensus: Diagnosis and Management of Sport-Related
Concussion Guidelines. The student athlete’s academic counselor will be the liaison between
the medical staff and academics and will help with any modifications that are needed to the
student athlete’s academic schedule. Student disability services, other physicians/specialists
(included but not limited to, psychologist, neuropsychologist or, college administrators) will
be utilized if needed in the transition back to the class room in a manner that is ADAAA
compliant. Students athletes with symptoms lasting longer than 2 weeks such as sleep
dysfunction, migraines, ocular or vestibular dysfunction or any other mood disorders will be
evaluated by the team physician and referred to other specialists as needed.
Reducing Head Trauma Exposure
Coaches will be educated to the fact that minimizing head trauma exposure during practices could
potentially decrease the amount of MTBI/Concussions. Information from the Year Round Football
Practice Contact Guidelines will be recommended as well as coaching proper technique will be
emphasized in order to prevent MTBI/Concussion.
MODIFIED BESS BASELINE
ATHLETE’S NAME:_________________________ DATE OF BASELINE: _______________
This balance testing is based on a modified version of the Balance Error Scoring System (BESS).
Balance Testing
“I am now going to test your balance. Please take your shoes off, roll up your pants legs above ankle. This test
will consist of 3- twenty second tests with different stances.”
(a) Double Leg Stance:
“Please stand with your feet together, hands on your hips, and with your eyes closed. You should try to maintain
stability in that position for 20 seconds. I will be counting the number of times you move out of this position. I
will start timing when you are set and have closed your eyes.”
(b) Single Leg Stance:
“Stand on your Non-Dominant foot. The dominant leg should be held at 30deg of hip flexion and 45deg of knee
flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and eyes
closed.”
(c) Tandem Stance:
“Now stand heel-to-toe with your non-dominant foot in back. Again, you should try to maintain stability for 20
seconds with your hands on your hips and eyes closed. If you stumble out of this position, open your eyes and
return to the start position and continue balancing.”
Balance testing – types of error
1. Hands lifted off iliac crest
2. Opening eyes
3. Step, stumble, or fall
4. Moving hip into > 30deg abduction
5. Lifting forefoot or heel
6. Remaining out of test position > 5sec
Each of the 20sec trials is scored by counting the # of errors. The modified BESS is calculated by adding one
error point for each error during the trials. The maximum total # of errors for any single trial is 10. Subjects that
are unable to maintain the testing procedure for a minimum of 5sec are assigned a “10” for total number of
errors.
Which foot was tested? L R
Test Description Score
Double Leg Stance _____ of 10
Single Leg Stance _____ of 10
Tandem Stance _____ of 10
BESS Score = 30 minus # of Errors
BESS SCORE _____ of 30Graduated Return-to-Play Protocol*
Rehabilitation stage Functional exercise at each stage of rehabilitation Objective of each stage
1. No activity. Symptom-limited physical and cognitive rest. Recovery.
2. Light aerobic exercise. Walking, swimming or stationary cycling keeping Increase heart rate.
intensity less than 70 percent maximum permitted
heart rate. No resistance training.
3. Sport-specific exercise. Skating drills in ice hockey, running drills in soccer. Add movement.
No head-impact activities.
4. Noncontact training drills. Progression to more complex training drills, Exercise,
coordination
e.g. passing drills in football and ice hockey. and cognitive load.
May start progressive resistance training.
5. Full-contact practice. Following medical clearance, participate in normal Restore confidence
training activities. and assess functional skills by coaching staff.
6. Return to play. Normal game play
* 2013 International Conference on Concussion in Sport. Zurich, Switzerland.CONCUSSION FLOW CHART
Head Injury
Evaluate: Concussion Evaluate: No Concussion
Remove from Competition Return to Competition
Within 1st 24 hours
• SCAT 3
• Eval by Physician if available
24 hours post-incident
• SCAT 3 Symptom Evaluation
• Eval/Consult by Physician
Self Report Symptomatic Step 1 SRA
• Cont SCAT3 Symptom • ImPACT
Evaluation every 24 • SCAT 3
hours until Self-Report
Asymptomatic (SRA) Step 2 SRA
• ImPACT
• Gradual Return to
Physical Exertion
If symptoms recur while
performing one of the SRA
steps, wait 24 hours, then Step 3 SRA
proceed with the same level • Return to full sport
as before. participation
Once asymptomatic,
proceed to the next step Reevaluation by Team
Physician and/or designee for
full return to activityCONCUSSION: HOME INSTRUCTION SHEET
Name: ________________________________ Date___________
You have had a head injury or concussion and need to be watched closely for the next 24-48 hours.
IT IS OK TO: DO NOT:
- Use Tylenol (acetaminophen) - Drink ALCOHOL
- Apply ice to head/neck for comfort - Eat spicy foods
- Eat a light meal - Use aspirin, Aleve, Advil (Ibuprofen),
- Go to sleep or any other NSAID products
WATCH FOR ANY OF THE FOLLOWING PROBLEMS:
Worsening headache Stumbling/loss of balance
Vomiting Weakness in one arm/leg
Decreased level of consciousness Blurred Vision
Dilated (large) pupils Increased irritability
Increased confusion
If any of these problems develop, call your athletic trainer immediately.
Athletic Trainer: ____________________ Phone: ____________
Recommendations provided to: __________________________
Recommendations provided by: __________________________STUDENT-ATHLETE RESPONSIBILITY TO REPORT
SIGNS AND SYMPTOMS OF CONCUSSION
Signs and Symptoms of Concussions
- Amnesia - Sensitivity to light
- Confusion - Sensitivity to noise
- Headache - Nausea
- Loss of consciousness - Feeling sluggish, foggy, or groggy
- Balance problems - Feeling unusually irritable
- Dizziness - Concentration problems
- Memory Problems - Slowed reaction time
I accept responsibility for reporting any injuries or illnesses to the Ole Miss
Sports Medicine staff, including signs and symptoms of concussions.
My signature below shows that I acknowledge and have been presented with
educational material regarding concussions, and understand that it is my
responsibility to report any signs and symptoms.
_________________________ _______________
Print Name Sport
_________________________ _______________
Student-Athlete Signature DateCONCUSSION
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 from contact with You can’t see a concussion, but you might notice some of the
another player, hitting a hard surface such as the ground, symptoms right away. Other symptoms can show up hours or days
floor, or being hit by a piece of equipment such as a bat, or after the injury.
ball, etc.
• Can change the way your brain normally works. Concussion symptoms include:
• Can range from mild to severe. • Amnesia.
• Presents itself differently for each athlete. • Confusion.
• Can occur during practice or competition in ANY sport. • Headache.
• Can happen even if you do not lose consciousness. • Loss of consciousness.
• Balance problems or dizziness.
• Double or fuzzy vision.
HOW CAN I PREVENT A CONCUSSION? • Sensitivity to light or noise.
Basic steps you can take to protect yourself from concussion: • Nausea (feeling that you might vomit).
• Do not initiate contact with your head or helmet. You can • Feeling sluggish, foggy or groggy.
still get a concussion if you are wearing a helmet. • Feeling unusually irritable.
• Avoid striking an opponent in the head. Undercutting, flying • Concentration or memory problems (forgetting plays, facts,
elbows, and stepping on a head are all ways to cause meeting times).
concussion. • Slowed reaction time.
• Follow your athletics department’s rules for safety and the
rules of the sport. Exercise or activities that involve a lot of concentration, such as
• Practice good sportsmanship at all times. studying, working on the computer, or playing video games may cause
• Practice and perfect the skills of the sport. concussion symptoms (such as a 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.
For more information visit www.NCAA.org/health-safety
Get checked out. Your Sports Medicine Staff 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 reactions 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.
WHEN IN DOUBT,
GET CHECKED OUT.You can also read
