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Avera St. Luke's Hospital

305 South State Street
Aberdeen, SD 57401
605-622-5000‎

Sports Medicine

  • Avera Avera St. Luke’s Concussion Management Plan and Guidelines

Avera St. Luke’s Concussion Management Plan and Guidelines

April 2011 

Introduction/Philosophy

The Sports Medicine Department at Avera St. Luke’s would like to ensure that every student-athlete participating in high school or collegiate athletics can do so safely and without potential long-term effects as a result of repeated exposure to concussions and other traumatic brain injuries. Therefore, Avera St. Luke’s Sports Medicine Department, in accordance with NCAA legislation and policy, and South Dakota SB 149, is implementing a formal concussion management policy. The purpose of this policy is to assist in the recognition, assessment, and treatment of concussions as well as a return to participation plan.

What is a Concussion?

A concussion is a metabolic disruption of the brain as a result of direct (hitting the head on the ground or other solid object) or indirect (whiplash) impact to the head. The energy (torque) from the impact is transferred through, to the brain and the brain will then make contact with the skull (coup/contra-coupe) as well as possibly twist or stretch (sheering). This impact to the brain can range from mild to severe and can determine the symptoms the athlete will experience. Loss of consciousness does not have to happen for a concussion to occur, but if a loss of consciousness does happen then a concussion has occurred.

Once the concussion has occurred, the brain attempts to repair itself using intracellular pumps to restore chemical imbalance. This chemical disruption causes the brain to demand more energy than normal while only being able to deliver half as much energy to the brain cells as usual because of the decreased blood and oxygen flow to the brain. This imbalance mismatch between supply and demand of energy causes the concussion symptoms.

Signs and Symptoms of Concussion:

There are a number of different signs and symptoms associated with a concussion, and the symptoms will present themselves differently in each athlete. The symptoms themselves can range from mild to severe. These symptoms can occur immediately following the injury or sometimes in the hours and days following the injury. Symptoms may also resolve quickly or linger for days and weeks.

Symptoms of concussions include:

  • Amnesia or memory loss
  • Confusion
  • Headache
  • Loss of Consciousness
  • Balance problems
  • Dizziness
  • Double or fuzzy vision
  • Light sensitivity
  • Noise sensitivity
  • Ringing in the ears
  • Nausea
  • Fatigue
  • Feeling as though you are “in a fog”
  • Feeling unusually irritable
  • Tearfulness/sadness/uncontrollable laughing
  • Decreased appetite
  • Decreased sleep
  • Increased sleep
  • Trouble falling asleep
  • Anxiety
  • Difficulty concentrating
  • Slowed reaction time

Student Athlete Protocol for Prevention and Care

If a student-athlete believes that they or a teammate is exhibiting the above signs of a concussion at any time, they should inform a coach or health care professional immediately so that an evaluation can occur and proper steps can be taken to care for the injury. Avera St. Luke’s Sports Medicine staff members are well trained in this evaluation and care.

Student-athletes can take a number of steps to help prevent concussions as well as worsening of symptoms. Student-athletes in contact sports should not initiate contact with an opponent using the head or helmet. Also, student-athletes should not strike opponents in the head with hands, fists, elbows or equipment.

Student-athletes should be sure to take as much time as needed to recover from a concussion. Additional trauma to the brain while it is still trying to heal increases the likelihood of a repeat concussion and a worsening of associated symptoms. In rare cases, repeat concussions can cause severe and permanent brain damage and be potentially fatal.

Additionally, a number of regular activities can exacerbate the symptoms experienced during concussion and should be avoided as much as possible. Activities such as exercise, studying, working on computers, playing video games and anything that involves physical exertion and/or high levels of concentration (and environments with high levels of stimulus) should be avoided.

For information on concussions go to www.cdc.gov/TraumaticBrainInjury/

Coach Protocol for Prevention and Care

In addition to the previously listed signs and symptoms, student-athletes with a concussion may also exhibit these signs while on the playing field:

  • Appearing dazed and confused
  • Confusion about position or game assignment
  • Forgetting plays or assignments during plays
  • Moves on the field slowly or clumsily.
  • Answers questions slowly.
  • Is unsure of where they are, score of the game or opponent.
  • Student-athlete holds their head or starts shaking their head repeatedly.

If a student athlete exhibits any of the signs and symptoms of concussion they should be removed from the playing field immediately so that an evaluation by a healthcare professional can be performed. At this moment (for events staffed by Avera St. Luke’s Sports Medicine), a sideline assessment for concussion will be conducted by a member of the Sports Medicine staff (athletic trainer or physician) and items such as memory, concentration, balance, etc. will be examined. Early evaluation of a possible head injury is of utmost importance when a concussion is suspected by a member of the coaching staff. If a concussion is diagnosed by a member of the Sports Medicine team, do not allow the student-athlete to return to play until they have followed the return to play procedure and have been cleared to return to play by a healthcare professional recognized in SD SB 149.

Avera St. Luke’s Sports Medicine requires clearance to play at Northern State University be provided by the following individuals: Jeff Bock, MD; Farook Kidwai, MD; Charles Pelton, PAc. Understand that concussion management has gotten progressively more conservative over the years to protect the long term well being of the student-athlete, and their return to physical activity may be a prolonged process as long as they continue to show symptoms. Repeated incidence of concussion, before the brain has had a chance to fully heal from the previous concussion, has been shown to delay full recovery and increase the likelihood of having long-term issues such as swelling of the brain, permanent brain damage and even death.

Prevention of concussions and the long term effects of repeated concussions from a coaching standpoint can be as easy as teaching student-athletes proper technique, especially in contact sports. Instructing student athletes to not use their head to initiate contact with an opponent as well as refrain from hitting their opponents in the head with hands, fists, elbows, and equipment can reduce the incidence of concussion greatly. Coaches should encourage student-athletes to practice and maintain good sportsmanship at all times. Also, coaches should purchase protective gear that meets the minimum standards for head protection for their student-athletes, as well as inspect the gear frequently to ensure that the equipment is being used properly, fits correctly and has no defects.

Another action that may be taken is to encourage your student-athletes to engage in neck muscle strengthening, while working with the Strength and Conditioning Coaches. This has been shown to decrease the incidence of concussion. Lastly, coaches should encourage an environment that supports reporting possible concussions, access to prompt medical evaluation and conservative return-to-play protocols.

Return-to-Play Protocol

If a student-athlete has been diagnosed with a concussion, they must follow this physician-directed return-to-play protocol, under the guidance of the Sports Medicine staff, before being allowed back onto the field of play without limitations. Each step in the progression from complete rest to return to play should besupervised and guided by a member of Avera St. Luke’s Sports Medicine staff, or another licensed health care professional. The student-athlete must be symptom-free for a minimum of 24 hours between steps in the progression. If symptoms return at any point during the progression to return to play, the student-athlete will discontinue the activity they were engaged in and will rest until they are symptom-free for 24 to 72 consecutive hours once again, depending on severity of the concussion and relapse of symptoms. At that point, they will re-start the progression back to full participation from the beginning. The only physical activity that the student-athlete is allowed to complete is that which is guided and supervised by a member of the Avera St. Luke’s Sports Medicine department or the supervising health care professional. This also includes all weight lifting and conditioning sessions that may occur while the athlete is recovering.

The Return-to-Play Protocol is as follows

Legally outlined in SB 149:

No athlete who has been removed from participation in an athletic activity sanctioned by the

South Dakota High School Activities Association may return to athletic activities until the athlete:

(1) No longer exhibits signs, symptoms, or behavior consistent with a concussion; and

(2) Receives an evaluation by a licensed health care provider trained in the evaluation and

management of concussions and receives written clearance to return to play from such

health care provider.

Section 5. For the purposes of this Act, a licensed health care provider is a person who is:

(1) Registered, certified, licensed, or otherwise recognized in law by the State of South

Dakota to provide medical treatment; and

(2) Trained and experienced in the evaluation, management, and care of concussions.

Avera St. Luke’s Sports Medicine has the following policy for Northern State University athletes and recommends for all athletes:

  • The student-athlete will be out of all physical activity until they are completely symptom-free for a 24-hour period. During this phase of complete rest, the student-athlete should refrain from any activities that may exacerbate symptoms. These activities include: any physical activity, computer work, watching television for prolonged periods of time, playing video games, and anything else that requires high levels of concentration. The student-athlete will be asked to take the SCAT-2 concussion test and/or the ImPACT re-test to assess the student-athletes neurological status at the time of injury. For information on ImPACT testing please see below.

    Once the student-athlete is symptom-free for 24 consecutive hours they will be neurologically tested again (either SCAT-2 or ImPACT). If their status has improved to near their previously established baseline levels (ImPACT testing) or the symptom score is low (SCAT-2), the student-athlete will be allowed to complete light aerobic exercise in the form of riding an exercise bike for 20 to 30 minutes at 60 to 70 percent of their max. If they experience symptoms of concussion at anytime during the exercise, they will stop immediately and they will have to be 24 hours symptom free until they can attempt light aerobic exercise again.

  • If the student-athlete is symptom-free for the 24 hours after the light aerobic exercise, the student-athlete will be allowed to engage in non-contact sport specific activities (ex. Shooting, dribbling, throwing) as well as non-contact practice drills at the discretion of the Sports Medicine staff. As before, if a return of concussion symptoms occur, the student-athlete will discontinue the activity and be placed on full rest again. If this part of the progression is met without complications for a 24 hour period, the Sports Medicine department will seek medical clearance to return to contact practice from a Northern State University team physician.
  • Once the student-athlete receives medical clearance from a Northern State University team physician, they will be allowed to participate in a full contact practice while under the careful supervision and guidance of the Sports Medicine department. Just as before, if the symptoms recur while the student-athlete is practicing, the student-athlete will be removed from the activity and be on full rest again.
  • The student-athlete will be allowed to return to normal activity and game play if they remain symptom-free for the 24 hours following the full contact practice. At this point, the student-athlete is allowed to return to weight lifting and conditioning as well as full participation in practice and competitions. 

Following 24 hours of being symptom free, the progression from full rest to symptom-free full participation should take around four days as long as the student-athlete is able to complete all the tasks in the progression without a relapse of concussion symptoms. The student-athlete should not be rushed back to the playing field, court, weight room, etc. until their brain is able to handle the stress of the activity. This protocol will ensure that the student-athlete will not return before their brain is fully healed from a concussion and reduce the risk of further injury and prolonged concussion symptoms.

Procedures for Prevention and Care:

Any student-athlete who demonstrates any of the above behaviors, signs, and/or symptoms of a concussion will be removed from all practice, weight lifting/conditioning sessions, and competitions until they can be evaluated by a member of the Sports Medicine staff in the form of an athletic trainer and/or team physician. This includes any symptoms that result from non-sport participation. Any student-athlete that has been diagnosed with a concussion will be removed from participation for the remainder of that day.  The student-athlete in question will need to obtain medical clearance from a team physician and/or satisfy the physician directed concussion management plan that will be outlined below.

All student-athletes, prior to participation with any university sanctioned athletic team, will sign the Assumption of Risk statement stating that they are responsible for reporting all injuries and illnesses to the Northern State University sports medicine staff, including all signs, symptoms and behaviors of concussions.

All student-athletes who have been previously diagnosed with a concussion will receive ImPACT baseline testing. Baseline testing will also occur if it is requested by the student-athlete or recommended by a Northern State University team physician. Additionally, student-athletes of the following sports will receive ImPACT baseline testing during their Pre-Participation Physical Examination or Health Appraisals: Football, Women’s Soccer, Volleyball, Men’s Basketball, Women’s Basketball, Baseball, Softball, Wrestling, as well as Men’s and Women’s Pole Vaulters.

ImPACT Concussion Management

Overview and Features of the ImPACT Test

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is the first, most widely used, and most scientifically validated computerized concussion evaluation system.

Developed in the early 1990s by Drs. Mark Lovell and Joseph Maroon, ImPACT is a 20-minute test that has become a standard tool used in comprehensive clinical management of concussions for athletes of all ages.

Given the inherent difficulties in concussion management, it is important to manage concussions on an individualized basis and to implement baseline testing and/or post-injury neurocognitive testing. This type of concussion assessment can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussion. In fact, neurocognitive testing has recently been called the "cornerstone" of proper concussion management by an international panel of sports medicine experts.

ImPACT can be administered by an athletic trainer, school nurse, athletic director, team coach, team doctor, or anyone trained to administer baseline testing. ImPACT is the most widely used computer-based testing program in the world and is implemented effectively across high school, collegiate, and professional levels of sport participation.

Test Features

  • Measures player symptoms
  • Measures verbal and visual memory, processing speed and reaction time
  • Reaction time measured to 1/100th of second
  • Assists clinicians and athletic trainers in making difficult return-to-play decisions
  • Provides reliable baseline test information
  • Produces comprehensive report of test results
  • Results can be e-mailed or faxed for fast consultation by a neuropsychologist
  • Automatically stores data from repeat testing
  • Testing is administered online for individuals or groups
  • Compatible with PC and MAC

The test battery consists of a near infinite number of alternate forms by randomly varying the stimulus array for each administration. This feature was built in to the program to minimize the "practice effects" that have limited the usefulness of more traditional neurocognitive tests.

ImPACT takes approximately 20 minutes to complete. The program measures multiple aspects of cognitive functioning in athletes, including:

  • Attention span
  • Working memory
  • Sustained and selective attention time
  • Response variability
  • Non-verbal problem solving
  • Reaction time

For more information on the ImPact Test please see visit http://impacttest.com/

ImPact is utilized by many professional sports leagues including NFL, MLB, NHL, etc. and also many universities, high schools and club sports. Schools in the Aberdeen area who utilize ImPACT include Northern State University, Presentation College, Aberdeen Central High School and Aberdeen Roncalli High School. 

Balance Testing

In addition to ImPACT, Avera St. Luke’s Sports Medicine Department can also perform balance/physical tests to help with return to play decisions. Staff will utilize the Balance Master to determine if the concussion effects are still affecting athletes balance.

For More Information

For more information on Concussion Management please contact Theresa Backous, Avera St. Luke’s Sports Medicine manager, at 605-626-7733 or email at 

theresa.backous@avera.org or theresa.backous@northern.edu