14 AFL MEDICAL OFFICERS ASSOCIATION

Notes

THE MANAGEMENT OF CONCUSSION IN

AUSTRALIAN FOOTBALLAFL ReseARch boARd

AFL MedIcAL oFFIceRs AssocIATIoN

THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 3

summary■ Concussion refers to a disturbance in brain function caused by trauma.

■ Complications can occur if the player is returned to play before having fully recovered from injury.

■ The key components of management include:

a) suspecting the diagnosis in any player with symptoms such as confusion or headache after a knock to the head;

b) Referring the player for medical evaluation; and

c) ensuring that the player has received medical clearance before allowing a return to play or a graded training program.

■ The cornerstones of medical management include rest until symptoms have resolved; cognitive testing to ensure recovery of brain function, and then a graded return to sport program with monitoring for recurrence of symptoms.

■ In general, a more conservative approach (i.e. longer time to return to sport) is used in cases where there is any uncertainty about the player’s recovery (“if in doubt sit them out”).

■ Difficult cases, such as those involving prolonged symptoms or deficits in brain function, require a more detailed, multi-disciplinary approach to management.

A player with suspected concussion must be withdrawn from playing or training until medically evaluated and cleared.

THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL

AFL Medical Officers Association Position Statement

This document has been produced by the AFL following an AFL Research board project, carried out by dr Michael Makdissi, and endorsed by the AFL Medical officers’ Association as a Position

statement on the Management of concussion in Australian Football.

The guidelines should be adhered to at all times. decisions regarding return to play after concussive injuries should only be made by a medical doctor with experience in concussive injuries.

August, 2008

THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL

4 AFL MEDICAL OFFICERS ASSOCIATION THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 5

BackgroundConcussion is a relatively common injury in Australian Football. It reflects a disturbance in brain function caused by trauma, rather than a structural injury. Resulting symptoms and changes in brain function are temporary and recover spontaneously. The recovery process however, is variable from person to person and injury to injury and may take from just a few minutes through to several weeks.

Symptoms of concussion typically include headache, blurred vision, dizziness and nausea. Brain function is also affected. Changes include confusion, memory loss and reduced ability to think clearly, concentrate and process information. These deficits can impair the way a player reacts during competition, which may put player at risk of further head or musculoskeletal injury. Repeated head injury, particularly when the player has not yet fully recovered from a previous head injury, has been linked with a number of potential complications, such as prolonged symptoms and long-term deterioration of brain function. Therefore, it is important to make the diagnosis and manage the condition appropriately. This means keeping the player out of training and competition until fully recovered.

This document approved by the AFL Medical Officers’ Association summarises the specific management guidelines developed for care of Australian Football players following a concussive injury.

Overall, these guidelines should serve only as a general guide for the management of concussive injuries sustained in Australian Football based on the most up-to-date evidence available. Treatment of individual players will be determined by the experience of the examining practitioner, the specific clinical circumstances presented and the resources available for assessment and testing.

6 AFL MEDICAL OFFICERS ASSOCIATION THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 7

Management guidelines

Game-day evaluation and treatmentThe key components of initial management involve making an accurate diagnosis and careful monitoring of the injured player.

1. on-field

■ Loss of consciousness (LOC), confusion, and memory disturbance are classic features of concussive injuries, but these are not present in every case of concussion.

■ Other symptoms that should raise suspicion of a concussive injury include: headache, blurred vision, balance problems, dizziness, feeling “dinged” or “dazed”, a player saying “I don’t feel right”, drowsiness, fatigue, difficulty concentrating or difficulty remembering.

■ Any player with a suspected concussive injury must be removed from the field of play for further evaluation.

■ The diagnosis can be confirmed using sideline mental status assessment tools, such as the Sideline Concussion Assessment Tool (SCAT).

■ Basic first-aid principles apply when dealing with any unconscious player (i.e. airways, breathing, circulation). Care must be taken with the player’s cervical spine, which may have also been injured in the collision.

2. sideline evaluation

■ Regular reassessment of symptoms and brain function in the hours following injury is essential to monitor for deterioration. This helps differentiate concussion (improvement) from structural head injuries (deterioration).

■ Indications for referral to hospital are listed in Table 1.

■ Overall, if there is any doubt, the patient should be referred to hospital.

■ If the player is being discharged home, clear and practical instructions, particularly regarding abstinence from alcohol and driving, medication use, physical exertion and medical follow up, should be given to the player and relevant caregivers (e.g. parents, partner, etc).

■ Tools such as the SCAT facilitate regular re-assessment of concussed players and provide simple and practical advice for patient education (see attachment). It is important to note that abbreviated sideline evaluation tools are designed for rapid concussion evaluation. They are not meant to replace a more comprehensive cognitive assessment and should not be used as a stand-alone tool for the ongoing management of concussive injuries.

3. Follow-up

■ Any player who has suffered from a concussive injury must be referred for medical evaluation and clearance before being allowed to return to training.

Table 1. Indications for referral to hospital

➤ Deterioration of conscious state post-injury (e.g. increased drowsiness).

➤ Focal neurological signs (e.g. numbness or weakness in the arms or legs).

➤ Prolonged confusion (for more than 30 minutes) or loss of consciousness for more than one minute.

➤ Persistent vomiting or increasing headache post-injury.

➤ Where there is difficulty with assessment or uncertain follow-up

➤ Children (under 18) with head injuries.

➤ High-risk patients (e.g. haemophilia, use of blood thinners).

8 AFL MEDICAL OFFICERS ASSOCIATION THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 9

Return-to-play decisionsThe basic principle of return-to-play decisions following concussive injury is to ensure that the player has fully recovered before being allowed to return to competition. In practical terms, this means resting the player until symptoms have resolved, then performing an objective test to assess recovery of brain function, followed by a graded return to play with monitoring for recurrence of symptoms (“concussion rehabilitation”).

■ In every case, decisions regarding the timing of return to training should be made by a medical doctor with experience in concussive injuries. Do not be swayed by the opinion of players, coaching staff or others suggesting premature return to play.

■ Cognitive tests can be used to assess recovery of brain function. These tests should be performed after symptoms have resolved. The important aspects of this testing involve comparing the post-concussion results to the players’ own pre-injury baseline and using a test that is sensitive to the effects of concussion. Ideally, computerised test platforms should be used, however, paper-and-pencil tests such as the Digit Symbol Substitution Test (with a more conservative return-to-play approach) are useful in cases where costs and time restrictions limit the use of computerised testing. Overall, it is important to remember that cognitive testing is only one component of assessment, and therefore should not be the sole basis of management decisions.

■ In general, a more conservative approach (i.e. longer time to return to sport) is used in cases where there is any uncertainty about the player’s recovery (“if in doubt sit them out” ).

Return to play on the day of injury■ In general, the safest course of action is that the player not be allowed

to return to play in the game or training session.

concussion rehabilitation■ Following a concussive injury players should be returned to play in a

graded fashion (see Table 2).

■ If symptoms recur at any stage of the “concussion rehab”, the player

should be re-evaluated by their treating doctor.

complex concussions■ “Complex concussions” are cases in which symptoms or changes

in brain function persist for more than 10 days, where the player has suffered multiple concussions over time or where the player has sustained a significant injury in response to a minor blow.

■ These cases are best managed in a multi-disciplinary manner by doctors with specific expertise in concussive injuries.

Table 2. concussion rehabilitation

Early rest (do nothing!).

Graduated return to activity (to commence 24-48 hours after resolution of symptoms).

1. Light aerobic exercise e.g. stationary bike.

2. Running.

3. Non-contact training drills.

4. Full contact training.

5. Game play.

10 AFL MEDICAL OFFICERS ASSOCIATION THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 11

The

Scat

Car

d

Spor

t Con

cuss

ion

Asse

ssm

ent T

ool

Spor

t Co

ncus

sion

Ass

essm

ent

Tool

(SC

AT)

Th

e SC

AT

Car

d (S

port

Con

cuss

ion

Ass

essm

ent T

ool)

Ath

lete

Info

rmat

ion

Wha

t is

a co

ncus

sion

? A

con

cuss

ion

is a

dis

turb

ance

in th

e fu

nctio

n of

the

brai

n ca

used

by

a di

rect

or i

ndire

ct fo

rce

to th

e he

ad.

It re

sults

in a

var

iety

of s

ympt

oms

(like

thos

e lis

ted

belo

w) a

nd m

ay,

or m

ay n

ot, i

nvol

ve m

emor

y pr

oble

ms

or lo

ss o

f con

scio

usne

ss.

H

ow d

o yo

u fe

el?

You

sho

uld

scor

e yo

urse

lf on

the

follo

win

g sy

mpt

oms,

bas

ed o

n ho

w y

ou fe

el n

ow.

Wha

t sho

uld

I do?

A

ny a

thle

te s

uspe

cted

of h

avin

g a

conc

ussi

on s

houl

d be

re

mov

ed fr

om p

lay,

and

then

see

k m

edic

al e

valu

atio

n.

Sign

s to

wat

ch fo

r: P

robl

ems

coul

d ar

ise

over

the

first

24-

48 h

ours

. Y

ou s

houl

d no

t be

left

alon

e an

d m

ust g

o to

a h

ospi

tal a

t onc

e if

you:

H

ave

a he

adac

he th

at g

ets

wor

se

Are

ver

y dr

owsy

or c

an’t

be a

wak

ened

(wok

en u

p)

Can

’t re

cogn

ize

peop

le o

r pla

ces

Hav

e re

peat

ed v

omiti

ng

Beh

ave

unus

ually

or s

eem

con

fuse

d; a

re v

ery

irrita

ble

Hav

e se

izur

es (a

rms

and

legs

jerk

unc

ontro

llabl

y)

Hav

e w

eak

or n

umb

arm

s or

legs

A

re u

nste

ady

on y

our f

eet;

have

slu

rred

spe

ech

Rem

embe

r, it

is b

ette

r to

be s

afe.

Con

sult

your

doc

tor a

fter a

su

spec

ted

conc

ussi

on.

Wha

t can

I ex

pect

? C

oncu

ssio

n ty

pica

lly re

sults

in th

e ra

pid

onse

t of s

hort-

lived

im

pairm

ent t

hat r

esol

ves

spon

tane

ousl

y ov

er ti

me.

You

can

exp

ect

that

you

will

be

told

to re

st u

ntil

you

are

fully

reco

vere

d (th

at m

eans

re

stin

g yo

ur b

ody

and

your

min

d).

Then

, you

r doc

tor w

ill li

kely

ad

vise

that

you

go

thro

ugh

a gr

adua

l inc

reas

e in

exe

rcis

e ov

er

seve

ral d

ays

(or l

onge

r) b

efor

e re

turn

i ng

to s

port.

Spor

ts c

oncu

ssio

n is

def

ined

as

a co

mpl

ex

path

ophy

siol

ogic

al p

roce

ss a

ffect

ing

the

brai

n,

indu

ced

by tr

aum

atic

bio

mec

hani

cal f

orce

s. S

ever

al

com

mon

feat

ures

that

inco

rpor

ate

clin

ical

, pa

thol

ogic

al a

nd b

iom

echa

nica

l inj

ury

cons

truct

s th

at

may

be

utili

zed

in d

efin

ing

the

natu

re o

f a c

oncu

ssiv

e he

ad in

jury

incl

ude:

1.

Con

cuss

ion

may

be

caus

ed e

ither

by

a di

rect

blo

w

to th

e he

ad, f

ace,

nec

k or

els

ewhe

re o

n th

e bo

dy

with

an

'impu

lsiv

e' fo

rce

trans

mitt

ed to

the

head

. 2.

Con

cuss

ion

typi

cally

resu

lts in

the

rapi

d on

set o

f sh

ort-l

ived

impa

irmen

t of n

euro

logi

cal f

unct

ion

that

re

solv

es s

pont

aneo

usly

. 3.

Con

cuss

ion

may

resu

lt in

neu

ropa

thol

ogic

al

chan

ges

but t

he a

cute

clin

ical

sym

ptom

s la

rgel

y re

flect

a fu

nctio

nal d

istu

rban

ce ra

ther

than

st

ruct

ural

inju

ry.

4. C

oncu

ssio

n re

sults

in a

gra

ded

set o

f clin

ical

sy

ndro

mes

that

may

or m

ay n

ot in

volv

e lo

ss o

f co

nsci

ousn

ess.

Res

olut

ion

of th

e cl

inic

al a

nd

cogn

itive

sym

ptom

s ty

pica

lly fo

llow

s a

sequ

entia

l co

urse

. 5.

Con

cuss

ion

is ty

pica

lly a

ssoc

iate

d w

ith g

ross

ly

norm

al s

truct

ural

neu

roim

agin

g st

udie

s.

Rem

embe

r, co

ncus

sion

sho

uld

be s

uspe

cted

in th

e pr

esen

ce o

f AN

Y O

NE

or m

ore

of th

e fo

llow

ing:

S

ympt

oms

(suc

h as

hea

dach

e), o

r S

igns

(suc

h as

loss

of c

onsc

ious

ness

), or

M

emor

y pr

oble

ms

Any

ath

lete

with

a s

uspe

cted

con

cuss

ion

shou

ld

be m

onito

red

for d

eter

iora

tion

(i.e.

, sho

uld

not b

e le

ft al

one )

and

sho

uld

not d

rive

a m

otor

veh

icle

.

Post

Con

cuss

ion

Sym

ptom

s A

sk th

e at

hlet

e to

sco

re th

emse

lves

bas

ed o

n ho

w

they

feel

now

. It

is re

cogn

ized

that

a lo

w s

core

may

be

nor

mal

for s

ome

athl

etes

, but

clin

ical

judg

men

t sh

ould

be

exer

cise

d to

det

erm

ine

if a

chan

ge in

sy

mpt

oms

has

occu

rred

follo

win

g th

e su

spec

ted

conc

ussi

on e

vent

. It

shou

ld b

e re

cogn

ized

that

the

repo

rting

of

sym

ptom

s m

ay n

ot b

e en

tirel

y re

liabl

e. T

his

may

be

due

to th

e ef

fect

s of

a c

oncu

ssio

n or

bec

ause

the

athl

ete’

s pa

ssio

nate

des

ire to

retu

rn to

com

petit

ion

outw

eigh

s th

eir n

atur

al in

clin

atio

n to

giv

e an

hon

est

resp

onse

. If

poss

ible

, ask

som

eone

who

kno

ws

the

athl

ete

wel

l ab

out c

hang

es in

affe

ct, p

erso

nalit

y, b

ehav

ior,

etc.

Post

Con

cuss

ion

Sym

ptom

Sca

le

N

one

Mod

erat

e

Sev

ere

Hea

dach

e 0

1 2

3 4

5 6

“Pre

ssur

e in

hea

d”

0 1

2 3

4 5

6 N

eck

Pai

n 0

1 2

3 4

5 6

Bal

ance

pro

blem

s or

diz

zy 0

1

2 3

4 5

6 N

ause

a or

vom

iting

0

1 2

3 4

5 6

Vis

ion

prob

lem

s 0

1 2

3 4

5 6

Hea

ring

prob

lem

s / r

ingi

ng 0

1

2 3

4 5

6 “D

on’t

feel

righ

t” 0

1 2

3 4

5 6

Feel

ing

“din

ged”

or “

daze

d” 0

1

2 3

4 5

6 C

onfu

sion

0

1 2

3 4

5 6

Feel

ing

slow

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own

0 1

2 3

4 5

6 Fe

elin

g lik

e "in

a fo

g"

0 1

2 3

4 5

6 D

row

sine

ss

0 1

2 3

4 5

6 Fa

tigue

or l

ow e

nerg

y 0

1 2

3 4

5 6

Mor

e em

otio

nal t

han

usua

l 0

1 2

3 4

5 6

Irrita

bilit

y 0

1 2

3 4

5 6

Diff

icul

ty c

once

ntra

ting

0 1

2 3

4 5

6 D

iffic

ulty

rem

embe

ring

0 1

2 3

4 5

6 (fo

llow

up

sym

ptom

s on

ly)

Sad

ness

0

1 2

3 4

5 6

Ner

vous

or A

nxio

us

0 1

2 3

4 5

6 Tr

oubl

e fa

lling

asl

eep

0 1

2 3

4 5

6 S

leep

ing

mor

e th

an u

sual

0

1 2

3 4

5 6

Sen

sitiv

ity to

ligh

t 0

1 2

3 4

5 6

Sen

sitiv

ity to

noi

se

0 1

2 3

4 5

6 O

ther

: ___

____

____

____

0

1 2

3 4

5 6

For m

ore

info

rmat

ion

see

the

“Sum

mar

y an

d A

gree

men

t Sta

tem

ent o

f the

Sec

ond

Inte

rnat

iona

l S

ympo

sium

on

Con

cuss

ion

in S

port”

in th

e A

pril,

200

5 ed

ition

of t

he C

linic

al J

ourn

al o

f Spo

rt M

edic

ine

(vol

15

), B

ritis

h Jo

urna

l of S

ports

Med

icin

e (v

ol 3

9),

Neu

rosu

rger

y (v

ol 5

9) a

nd th

e P

hysi

cian

and

S

ports

med

icin

e (v

ol 3

3).

This

tool

may

be

copi

ed fo

r di

strib

utio

n to

team

s, g

roup

s an

d or

gani

zatio

ns.

©20

05 C

oncu

ssio

n in

Spo

rt G

roup

This

tool

repr

esen

ts a

sta

ndar

dize

d m

etho

d of

ev

alua

ting

peop

le a

fter c

oncu

ssio

n in

spo

rt. T

his

Tool

ha

s be

en p

rodu

ced

as p

art o

f the

Sum

mar

y an

d A

gree

men

t Sta

tem

ent o

f the

Sec

ond

Inte

rnat

iona

l S

ympo

sium

on

Con

cuss

ion

in S

port,

Pra

gue

2004

ww

w.c

jspo

rtm

ed.c

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12 AFL MEDICAL OFFICERS ASSOCIATION THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 13

McC

rory

, Joh

nsto

n, M

eeuw

isse,

et a

l

Spor

t Co

ncus

sion

Ass

essm

ent

Tool

(SC

AT)

Th

e SC

AT

Car

d (S

port

Con

cuss

ion

Ass

essm

ent T

ool)

Med

ical

Eva

luat

ion

Nam

e: _

____

____

____

____

____

____

__

Dat

e __

____

____

S

port/

Team

: ___

____

____

____

____

____

M

outh

gua

rd?

Y N

1)

SIG

NS

Was

ther

e lo

ss o

f con

scio

usne

ss o

r unr

espo

nsiv

enes

s?

Y

N

Was

ther

e se

izur

e or

con

vuls

ive

activ

ity?

Y

N

W

as th

ere

a ba

lanc

e pr

oble

m /

unst

eadi

ness

? Y

N

2)

MEM

OR

Y

Mod

ified

Mad

dock

s qu

estio

ns (c

heck

cor

rect

) A

t wha

t ven

ue a

re w

e? _

_; W

hich

hal

f is

it? _

_; W

ho s

core

d la

st?_

_ W

hat t

eam

did

we

play

last

? __

; Did

we

win

last

gam

e? _

_?

3) S

YMPT

OM

SC

OR

E

Tota

l num

ber o

f pos

itive

sym

ptom

s (fr

om re

vers

e si

de o

f the

car

d) =

___

___

4) C

OG

NIT

IVE

ASS

ESSM

ENT

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ord

(E

xam

ples

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once

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call

Imm

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Del

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____

____

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W

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____

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W

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Wor

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____

____

____

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___

___

W

ord

5 __

____

____

___

car

___

___

Mon

ths

in re

vers

e or

der:

Jun-

May

-Apr

-Mar

-Feb

-Jan

-Dec

-Nov

-Oct

-Sep

-Aug

-Jul

(c

ircle

inco

rrec

t) or

D

igits

bac

kwar

ds (c

heck

cor

rect

) 5-

2-8

3-9-

1 __

____

6-

2-9-

4 4-

3-7-

1 __

____

8-

3-2-

7-9

1-4-

9-3-

6 __

____

7-

3-9-

1-4-

2 5-

1-8-

4-6-

8 __

____

Ask

dela

yed

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reca

ll no

w

5) N

EUR

OLO

GIC

SC

REE

NIN

G

P

ass

Fail

Spe

ech

___

___

Eye

Mot

ion

and

Pup

ils

___

___

Pro

nato

r Drif

t __

_ __

_ G

ait A

sses

smen

t __

_ __

_

Any

neur

olog

ic s

cree

ning

abn

orm

ality

nec

essi

tate

s fo

rmal

ol

ogic

or h

ospi

tal a

sses

smne

uren

t 6)

RET

UR

N T

O P

LAY

Ath

lete

s sh

ould

not

be

retu

rned

to p

lay

the

sam

e da

y of

inju

ry.

Whe

n re

turn

ing

athl

etes

to p

lay,

they

sho

uld

follo

w a

ste

pwis

e sy

mpt

om-li

mite

d pr

ogra

m, w

ith s

tage

s of

pro

gres

sion

. Fo

r exa

mpl

e:1.

re

st u

ntil

asym

ptom

atic

(phy

sica

l and

men

tal r

est)

2.

light

aer

obic

exe

rcis

e (e

.g. s

tatio

nary

cyc

le)

3.

spor

t-spe

cific

exe

rcis

e

4.

non-

cont

act t

rain

ing

drill

s (s

tart

light

resi

stan

ce tr

aini

ng)

5.

full

cont

act t

rain

ing

afte

r med

ical

cle

aran

ce

6.

retu

rn to

com

petit

ion

(gam

e pl

ay)

Ther

e sh

ould

be

appr

oxim

atel

y 24

hou

rs (o

r lon

ger)

for e

ach

stag

e an

d th

e at

hlet

e sh

ould

retu

rn to

sta

ge 1

if s

ympt

oms

recu

r.

Res

ista

nce

train

ing

shou

ld o

nly

be a

dded

in th

e la

ter s

tage

s.

Med

ical

cle

aran

ce s

houl

d be

giv

en b

efor

e re

turn

to p

lay.

Ret

urn

to P

lay:

A

stru

ctur

ed, g

rade

d ex

ertio

n pr

otoc

ol s

houl

d be

de

velo

ped;

indi

vidu

aliz

ed o

n th

e ba

sis

of s

port,

age

an

d th

e co

ncus

sion

his

tory

of t

he a

thle

te.

Exe

rcis

e or

tra

inin

g sh

ould

be

com

men

ced

only

afte

r the

ath

lete

is

clea

rly a

sym

ptom

atic

with

phy

sica

l and

cog

nitiv

e re

st.

Fina

l dec

isio

n fo

r cle

aran

ce to

retu

rn to

com

petit

ion

shou

ld id

eall y

be

mad

e by

a m

edic

al d

octo

r.

Neu

rolo

gic

Scre

enin

g:

Trai

ned

med

ical

per

sonn

el m

ust a

dmin

iste

r thi

s ex

amin

atio

n. T

hese

indi

vidu

als

mig

ht in

clud

e m

edic

al

doct

ors,

phy

siot

hera

pist

s or

ath

letic

ther

apis

ts.

Spe

ech

shou

ld b

e as

sess

ed fo

r flu

ency

and

lack

of

slur

ring.

Eye

mot

ion

shou

ld re

veal

no

dipl

opia

in a

ny

of th

e 4

plan

es o

f mov

emen

t (ve

rtica

l, ho

rizon

tal a

nd

both

dia

gona

l pla

nes)

. Th

e pr

onat

or d

rift i

s pe

rform

ed

by a

skin

g th

e pa

tient

to h

old

both

arm

s in

fron

t of

them

, pal

ms

up, w

ith e

yes

clos

ed.

A p

ositi

ve te

st is

pr

onat

ing

the

fore

arm

, dro

ppin

g th

e ar

m, o

r drif

t aw

ay

from

mid

line.

For

gai

t ass

essm

ent,

ask

the

patie

nt to

w

alk

away

from

you

, tur

n an

d w

alk

back

.

Cog

nitiv

e A

sses

smen

t: S

elec

t any

5 w

ords

(an

exam

ple

is g

iven

). A

void

ch

oosi

ng re

late

d w

ords

suc

h as

"dar

k" a

nd "m

oon"

w

hich

can

be

reca

lled

by m

eans

of w

ord

asso

ciat

ion.

R

ead

each

wor

d at

a ra

te o

f one

wor

d pe

r sec

ond.

Th

e at

hlet

e sh

ould

not

be

info

rmed

of t

he d

elay

ed

test

ing

of m

emor

y (to

be

done

afte

r the

reve

rse

mon

ths

and/

or d

igits

). C

hoos

e a

diffe

rent

set

of

wor

ds e

ach

time

you

perfo

rm a

follo

w-u

p ex

am w

ith

e sa

me

cand

ida

th

te.

uenc

e.

Ask

the

athl

ete

to re

cite

the

mon

ths

of th

e ye

ar

in re

vers

e or

der,

star

ting

with

a ra

ndom

mon

th.

Do

not s

tart

with

Dec

embe

r or J

anua

ry.

Circ

le a

ny

mon

ths

not r

ecite

d in

the

corr

ect s

eqFo

r dig

its b

ackw

ards

, if c

orre

ct, g

o to

the

next

st

ring

leng

th.

If in

corr

ect,

read

tria

l 2.

Sto

p af

ter

inco

rrec

t on

both

tria

ls.

Mem

ory:

If n

eede

d, q

uest

ions

can

be

mod

ified

to

mak

e th

em s

peci

fic to

the

spor

t (e.

g. “

perio

d” v

ersu

s “ha

lf”)

For m

ore

info

rmat

ion

see

the

“Sum

mar

y an

d A

gree

men

t Sta

tem

ent o

f the

Sec

ond

Inte

rnat

iona

l S

ympo

sium

on

Con

cuss

ion

in S

port”

in th

e A

pril,

200

5 C

linic

al J

ourn

al o

f Spo

rt M

edic

ine

(vol

15)

, Brit

ish

Jour

nal o

fSpo

rts M

edic

ine

(vol

39)

, Neu

rosu

rger

y (v

ol

59) a

nd th

e P

hysi

cian

and

Spo

rtsm

edic

ine

(vol

33)

. ©

2005

Con

cuss

ion

in S

port

Gro

up

Inst

ruct

ions

: Th

is s

ide

of th

e ca

rd is

for t

he u

se o

f med

ical

doc

tors

, ph

ysio

ther

apis

ts o

r ath

letic

ther

apis

ts.

In o

rder

to

max

imiz

e th

e in

form

atio

n ga

ther

ed fr

om th

e ca

rd, i

t is

stro

ngly

sug

gest

ed th

at a

ll at

hlet

es p

artic

ipat

ing

in

cont

act s

ports

com

plet

e a

base

line

eval

uatio

n pr

ior t

o th

e be

ginn

ing

of th

eir c

ompe

titiv

e se

ason

. Th

is c

ard

is a

sug

gest

ed g

uide

onl

y fo

r spo

rts c

oncu

ssio

n an

d is

no

t mea

nt to

ass

ess

mor

e se

vere

form

s of

bra

in

inju

ry.

Plea

se g

ive

a C

OPY

of t

his

card

to th

e at

hlet

e fo

r the

ir in

form

atio

n an

d to

gui

de fo

llow

-u p

ass

essm

ent.

Sign

s:

Ass

ess

for e

ach

of th

ese

item

s an

d ci

rcle

Y

(yes

) or N

(no)

.

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