SUMMER 2012
SPORTS MEDICINE MAGAZINE
SPORTS MEDICINE MAGAZINE
SPORTS MEDICINE MAGAZINE
SPORTS MEDICINE MAGAZINE
SPORTS MEDICINE MAGAZINE
Concussion and Heat Issue
SUMMER 2012
Contents Page
Features
>Editor’s Note /// Gary A. Levengood, MD /// 3
>GMCSMC Concussion Position Statement /// 4-5
>Concussion Recognition /// By: Mark C. Cullen, MD /// 6
>The Treatment of Concussions and Necessary Provisions ///
By: Mathew Pombo, MD ///
8-9
>GMC’s ImPACT Program /// By: Tim Simmons, MHA, ATC, LAT /// 10-11
>Proper Football Helmet Fitting /// By: Sam Hadaway ATC, CSCS /// 12
>The Importance of the Properly Fitted Mouthguard in Athletics ///
By: Jeremy R. Smith, MD ///
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>Rachel Havens - From Darkness into Light /// By: Paige Havens /// 14-15
>Recognition and On-Field Treatment of Heat Illnesses and Heat Stroke ///
By: Stephanie H. Hsu, MD /// 16-17
>Exercise-Related Heat Illness /// By: Brian Morgan, MD /// 18-19
>Exertional Heat Illness Readiness Plan /// By: Jay Pearson ATC, LAT /// 20-22
>Preventing Dehydration During Summer Activities ///
By: Ann Dunaway Teh, MS, RD, LD ///
24
///
25
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Letter
from the
Editor <<<
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oncussions and heat illness may not only cause an immediate decrease in athletic performance, but more importantly, these injuries can easily lead to significant long
term mental and physical damage if not properly addressed. In
order to better educate the physicians and certified athletic trainers who care for these athletes, the coaches, parents, athletes
and general community who are involved with athletics, we have
dedicated this issue of GSSM magazine to this important topic.
Summertime is the season for relaxing beachside vacations
and lazy lake days; however, the summer break can also pose
extremely dangerous situations for many of our athletes. If the
proper precautions are not taken, sweltering temperatures and
humidity so prevalent in the south, easily create a hazardous environment to athletes’ health and their overall ability to perform at
the desired level. Heat illness and death is preventable and recognizing the causes and symptoms is paramount. Creating a safe
environment is the thrust of these articles. Any combination of heat,
dehydration, and exhaustion can be life threatening -- it should be
our priority, as parents, coaches, physicians, and as a community,
to properly educate ourselves on the safety measures, recognition,
and action plan necessary to prevent heat illness.
Concussions and their long term consequences have inundated
the airway lately. Many states have enacted laws to determine
when an athlete should not be returned to play. Our effort, in this
issue is to provide the tools necessary to recognize concussions
and then create and action plan for recovery. Additionally, articles
on helmet fitting and mouthguard choices were chosen to try
to prevent these injuries from occurring. Taking the time to adequately understand the severity of these injuries will help us to
ensure the safety of our athletic programs and the long-term wellbeing of the community’s athletes. Please take the time to read
through this important issue of GSMM so that you may further
educate yourself on the current measures that are being taken to
ensure the safety of our athletes.
We have assembled the top Sports Medicine Physicians and
Trainers in Georgia to write these articles and it is my hope you
find these both interesting and educational. Should you have any
question regarding the information in this magazine please feel
free to contact us at: [email protected]
If you would like to submit an article or are
interested in advertising opportunities
in GSMM please contact Sherri Cloud at
[email protected] or 678.907.2912
GSMM 3
GMCSMC Concussion Position Statement <<<
GMCSMC
Concussion
Position Statement
By: Matthew Pombo MD, Mark Cullen MD,
Gary Levengood MD, and Yvonne Satterwhite, MD
T
he CDC defines concussion as” A complex
pathophysiological process affecting the
brain, induced by traumatic biomechanical forces secondary to direct or indirect
forces to the head. Concussion is caused
by a jolt to the head or body that disrupts
the function of the brain. The disturbance
of brain function is typically associated with normal structural neuroimaging findings (i.e. CT, MRI). Concussions result in a constellation of physical, cognitive, emotional and/
or sleep-related symptoms and may or may not involve a
loss of consciousness. Duration of symptoms is highly variable and may last several minutes to days, weeks, months
or longer in some cases.”
A bump, blow or jolt to the head can cause a concussion,
a type of traumatic brain injury. Concussions can also occur
from a blow to the body that causes the head and brain to
move rapidly back and forth. Even a “ding”, “getting your bell
rung” or what seems to be a mild bump or blow to the head
can be serious. The potential for concussions is greatest in
athletic contests where collisions are common. Concussion
can occur, however, in any sport or recreational activity, as
well as outside of sport events such as motor vehicle accidents. A well fitting helmet or mouth guard may decrease the
likelihood of a concussion, but do not fully prevent it. Often
players do not realize that a bump, blow or jolt to the head
or body can cause a concussion, as historically concussions
were thought to occur only when someone was” knocked
out”. As a result, athletes may not receive medical attention at the time of the injury, but they later report symptoms
of headache, dizziness or difficulty remembering or concentrating. These as well as other symptoms can be a sign of
having sustained a concussion. A concussion unrecognized
or untreated may lead to the athlete returning to play prior
to the brain fully recovering from the first insult. This can
lead to “second impact syndrome”. In second impact syndrome, massive swelling of the brain causes pressure inside
the skull that chokes off the flow of fresh blood flow to the
brain leading to irreparable brain damage or death. Adolescent athletes who participate in contact sports are at an increased risk for concussion and second impact syndrome.
4 GSMM
When a concussion is suspected, at a
minimum the following is recommended:
• An athlete should be removed from further play that day.
• Ensure an athlete is evaluated by a Health Care
professional experienced in evaluating and treating
concussions.
• Initiate a parent action plan to notify the parents
and educate them on signs and symptoms as well
as warning signs in the acute setting.
• The athlete should be held out of play until they are
symptom free and have been cleared by a healthcare
professional.
Remember, you can’t see a concussion and some athletes may
not experience and/or report symptoms until hours or days after the
injury. Most people with a concussion will recover quickly and fully
with the average high school student taking 3-4 weeks. But for some
people, signs and symptoms of concussion can last even longer.
Exercising or activities that involve a lot of concentration, such as
focusing in the classroom, studying, working on the computer or
playing video games may cause concussion symptoms (such as
headache or tiredness) to reappear or get worse. After a concussion,
physical and cognitive activities – such as concentrating and learning – should be carefully managed and monitored by a healthcare
professional with a policy in place for academic accommodations
during recovery to not only provide the athlete with a safe physical
environment to heal in, but a safe academic involvement that doesn’t
worsen symptoms or delay recovery and allows the student-athlete
to not suffer academically at the same time.
The Gwinnett Medical Center Sports Medicine Committee (GMCSMC)
has recognized the increasing awareness of concussions and their
short and long-term consequences. Our student athletes deserve
the most aggressive and innovative concussion policies to allow
them to not only excel on our athletic fields safely, but also continue
to protect them academically. It is our position that change comes
from the top, and as Sports Medicine Health Care leaders, we believe it is time to institute new concussion recommendations to all
high schools and youth athletic programs. Our recommendations are
divided into three phases: Education, Recognition, and Treatment.
Education:
1. The GMCSMC recommends that all licensed high school coaches and Athletic
Directors in the Gwinnett County be required to complete continuing education
units yearly with competency testing on
the recognition and treatment of concussions in order to maintain licensure.
2. The GMCSMC recommends that each
high school develop and maintain a concussion action plan that identifies a healthcare
professional to respond to concussions during games and practices, that develops education opportunities (i.e. concussion symptom
cards) for coaches/athletic staff (administrators, counselors, and school nurses) in the
implementation of the action plan.
3. The GMCSMC recommends the education of teachers during pre-school planning
sessions and education packets to make
them aware of the difficulties kids with concussions can have in the classroom to better prepare them for providing and implementing academic accommodations and
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Recognition:
1. The GMCSMC supports the use of certified athletic trainers (ATCs) at every high school in Gwinnett County and
strongly recommends that each school have a full time ATC
on campus at practices and game of all contact sports to ensure better recognition and guidance with initiation of concussion action plans.
2. Parents and Athletes should be educated about the risks
involved with concussions in the modern era, as well as the
signs, symptoms, and dangers involved at preseason booster club meetings for each sport.
Treatment:
1. The GMCSMC recommends preseason neurocognitive
baseline testing for high school athletes to compare to when
an athlete sustains a concussion.
2. Any athlete that is suspected to have a concussion is removed from play immediately and not returned to play that
same day.
3. Any athlete with a concussion should be evaluated by a
healthcare professional experienced in treating concussions
to ensure the athlete receives appropriate treatment.
4. The GMCSMC recommends weekly neurocognitive testing to predict and monitor brain recovery.
5. No athlete should return to play until they are:
a. Asymptomatic at rest,
b. And asymptomatic with non-contact exertion,
c. And have returned to their baseline on neurocognitive
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/// By: Mark C. Cullen, MD
What is a concussion?
A concussion is brain injury. A concussion changes the
way the brain normally works. A concussion is caused by a
bump, blow, or jolt to the head. Even what seems to be a mild
bump to the head can cause a serious injury.
Concussions can have a more serious effect on a young,
developing brain and need to be treated properly.
Common features of concussion:
Every concussion is different, so treatment and recovery
time varies from individual to individual. But all concussions
are alike in five ways:
Direct blow to head not required. A concussion can be
caused by a direct blow to the head, face, neck, or elsewhere
on the body with a force transmitted to the head.
Rapid onset and gradual resolution of symptoms. A
concussion typically results in the rapid onset of symptoms
of impaired neurological function which gradually disappear
spontaneously with rest. Most concussions resolve over 2-4
weeks but some concussions take months to improve.
Brain function disrupted. A concussion disrupts normal
brain metabolism. This results in symptoms reflecting a disruption of the way the brain functions rather than a structural
injury to the brain itself.
Loss of consciousness not required. Concussions result
in a set of clinical symptoms that may or may not involve loss
of consciousness. Resolution of symptoms typically follow
a sequential course, but in some cases, post-concussive
symptoms may linger for a long period of time.
Normal MRI/CAT scans. Concussion is a metabolic injury
not a structural injury. CT scans and MRI are typically normal and in most concussions are not indicated.
What are the signs and
symptoms of a concussion?
Signs and symptoms of concussion can show up right after an injury or may not appear until hours or days after the
injury. Most concussions occur without a loss of consciousness. If your child reports or demonstrates one or more of
the symptoms of concussion listed below, seek medical attention right away.
SIgns observed by parents of guardians
• Appears dazed or stunned
• Is confused about events
• Answers questions slowly
• Repeats questions
• Can’t recall events prior to the hit, bump, or fall retrograde
• Can’t recall events after the hit, bump, or fall
• Loses consciousness (even briefly)
• Shows behavior or personality changes
• Forgets class schedule or assignments
Symptoms reported by your child or teen
Thinking/Remembering:
• Difficulty thinking clearly, Difficulty concentrating or remembering, Feeling more slowed down, Feeling sluggish, hazy,
foggy, or groggy
Physical:
• Headache or “pressure” in head, Nausea or vomiting,
Balance problems or dizziness, Fatigue or feeling tired,
Blurry or double vision, Sensitivity to light or noise,
Numbness or tingling, Does not “feel right”
Emotional:
• Irritable, Sad, More emotional than usual, Nervous
Sleep:
• Drowsy, Sleeping less or more than usual, Trouble falling asleep
When to seek immediate medical attention:
•
•
•
•
•
•
6 GSMM
•
•
•
•
Headache that gets worse and does not go away.
Weakness, numbness or decreased coordination.
Repeated vomiting or nausea.
Slurred speech.
Look very drowsy or cannot be awakened.
Have one pupil (the black part in the middle of the eye)
larger than the other.
Have convulsions or seizures.
Cannot recognize people or places.
Are getting more and more confused, restless, or agitated.
Lose consciousness
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The Treatment
of Concussions
and Necessary
Provisions
/// By: Mathew Pombo, MD
A
16
year
old,
Junior High
School
soccer player leaves
her feet to head a ball,
an opponent clips her
knees, and she falls to
the ground unprotected, striking her head
to the ground. Though
there is no loss of consciousness or mental
status changes, the
young girl perceives
some disturbing symptoms such as blurred
vision, dizziness when
she arises from the turf, a sense of fatigue, and a generalized
light pressure headache that seems to worsen with lights and
noise on the field. Undeterred, she is trained to be tough and
plays on, noticing that subsequent exertion seems to increase
the pressure in her headache. Ten minutes later, she heads an
oncoming ball and now her teammates notice that she is slow
to respond to questions and is even repeating herself. She
removes herself from the game under her own power, and now
begins our dilemma…
In this article, I hope to shed some light on the above scenario
to make the readers understand that there is really no dilemma
in the treatment/recovery of concussions. Where the dilemma
lies, is in educating the sports world (coaches, parents, athletes, etc.) to better recognize the signs and symptoms of a
concussion to increase our ability to diagnose them, and therefore, also our ability to treat them. In the scenario above, and
likely unbeknownst to this girls family, coaches, and even many
clinicians, critical decisions need to be made regarding her proper post-concussion evaluation and management.
Of concern is that an uneducated parent, coach, or clinician
may not be aware that mismanagement of this athlete, at this
8 GSMM
point, could lead to a rare incidence of sudden death from intracranial bleeding or second impact syndrome (second blow
to the head during a vulnerable phase during concussion recovery that leads to a sudden loss of autoregulation of the
brains’ blood supply resulting in acute brain swelling and often
sudden death); or situations that occur more frequently such
as a protracted or chronic presentation of potentially disabling
symptoms such as severe headaches, dizziness, neurobehavioral changes, and/or severe cognitive deficits that impair
academic functioning. Those involved may also not be aware
that until full recovery is achieved less biomechanical force/
blow to the head will extend recovery, that simple cognitive
exertion (i.e. studying and test taking in school) or physical
exertion (i.e. non-contact practice/conditioning/weight training) will extend the length of recovery, and that “recovery” is
a fairly well-defined criteria with a large amount of research
basis that has specific criteria that need to be achieved before
the athlete returns to play. It is no longer sit out a few days or
a week and then get back to it.
So what is a concussion? The CDC’s definition is: “…a complex-pathophysiological process affecting the brain, induced by
traumatic biomechanical forces secondary to direct or indirect
forces to the head. Concussion is caused by a jolt to the head
or body that disrupts the function of the brain. The disturbance
of brain function is typically associated with normal structural
neuroimaging findings (i.e. CT scan, MRI). Concussions result
in a constellation of physical, cognitive, emotional and/or sleeprelated 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 longer
in some cases.” A concussion is no longer defined as “getting
knocked out” or getting “your bell rung.” This injury is much more
complex and severe than what we have previously thought.
The first step in management of a concussion is RECOGNITION. The sideline presentation of an athlete with a concussion
may vary widely with symptoms ranging from those that are obvious to subtle findings that may not be present until they return
to school under cognitive loads. Many of these symptoms depend on the biomechanical forces involved, the severity of the
The Treatment of Concussions and Necessary Provisions <<<
injury, and the specific brain areas that are affected. The periconcussion presentation (24-48 hours around the injury) can be
divided into two areas: signs observed by coaches, parents,
medical staff, and symptoms reported by athletes. The signs
observed by coaches, parents, and medical staff may include
loss of consciousness, the appearance of being dazed, stunned,
confused, or forgetful. The athlete may be unsure of the game,
score, opponent or half they are playing and may move clumsily.
They may seem slowed down when trying to answer questions
and have amnesia about the event (i.e. forgetful of events before
or after the head trauma). Symptoms reported by the athlete
usually involved a headache that improves with rest and may
worsen with cognitive activity/school work. They can report nausea, dizziness, abnormal/blurry vision, sensitivity to lights/loud
noise, fatigue, and difficulty with memory/concentration. Some
specific findings may be feeling slowed down/sluggish, feeling
mentally foggy, and changes in sleep patterns.
Once a concussion is diagnosed the next phase becomes management, which is divided into on-field and off-field management.
The management of a concussion recognized during an athletic
event centers around acute evaluation and treatment. If LOC
occurs and the athlete is still on the field, an initial evaluation of
the cervical spine, airway, breathing, and circulation becomes of
utmost importance. If the athlete is awake and stable, they can
be transported to the sideline where monitoring of their mental
status and a sideline concussion evaluation takes place. In current concussion management NO athlete should return to play in
a game after a suspected/diagnosed concussion has occurred.
The parents/medical staff should have a high index of suspicion
and a low threshold to transport an athlete to the emergency
room for a higher acuity evaluation for unusual signs/symptoms
such as deteriorating level of consciousness, visual field cuts,
prolonged loss of consciousness, protracted vomiting that worsens, and younger children with unreliable physical exams.
The majority of concussions, 80% in fact, are not recognized/
diagnosed on the sidelines and may never be diagnosed at all.
The majority of concussions that I see are recognized/diagnosed
by students and/or parents that have worsening symptoms upon
return to school several days later. The goal at this phase is to
provide a safe environment for these athletes that includes all
aspects of their daily lives. Initial goals are to provide cognitive
and physical rest. Student-athletes are kept out of school for
cognitive rest for a day or two, followed by ½ day school for a day
or two. They are encouraged to avoid their symptoms, rest, and
limit it excessive cognitive stimuli. They are given academic
accommodations to provide an academic environment targeted to prevent their grades from suffering during their recovery. Only 40% of athletes with a concussion are better in 1
week, and only 80-90% are better at 3-4 weeks, so a concussion often affects an athlete in the classroom for several weeks,
a month, and in some cases longer.
Here in Gwinnett County, we have implemented a neurocognitive-testing program to assist in our athletes’ safe return to
participation. The program utilizes the ImPACT test, a computerized neurocognitive test battery, made available to all high
school athletes in Gwinnett provided by the Gwinnett Medical
Center’s Sports Medicine Program. This concussion program
provides baseline testing to all athletes prior to their respective sport season that establishes their cognitive baseline. This
provides a reference point for our athletic trainers and medical
staff to go by should an athlete suffer a suspected concussion
during their sport. If a concussion is suspected, the athlete
is retested with the ImPACT test 24-72 hours after their injury
and their brain function is compared to their baseline test to
see if it registers an abnormality. When an abnormality occurs, the athlete is held out of any physical activity and is followed weekly with ImPACT testing until their cognitive function
returns back to their baseline levels. Prior to returning to play,
a non-contact physical exertion protocol is performed to progressively increase the athlete’s heart rate over a several day
period to ensure that their symptoms do not return. They are
given a final ImPACT test prior to clearance/return to play to
ensure that their neurocognitive scores stay at baseline after
the exertion program. At that point the athlete is cleared to
return to their sport. On average a high school concussion is
a 3-4 week injury.
In summary, NO athlete should return to a game the day of
a suspected/diagnosed concussion. Return to play guidelines mandate that an athlete be asymptomatic at rest, asymptomatic with exertion, and have normal neurocognitive
testing. Old Grading Scales (Cantu, etc.) and AAN guidelines are no longer a valid treatment algorithm in the Sports
concussion arena. Concussions can have devastating effects on grades and classroom function. Should a concussion be suspected it is irresponsible to play through it. Concussions are a part of sports, and while we may never get
rid of them, we can arm ourselves with education to better
diagnose and treat them in hopes of helping to prevent the
devastating short term and long term complications that can
occur with these injuries.
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GMC’s
ImPACT
Program
GMC ImPACT POC Algorithm
Pre-season baseline testing completed
Student cleared to fully participate in athletics
YES
Immediate removal from activity w/ any s/s of concussion
ATC notifies parents and
provides written and
verbal home and follow
up care instructions.
ATC encourages athlete to rest and
avoid activity that increases symptoms
(school, video games, TV, etc) until
seen by MD.
/// By: Tim Simmons, MHA, ATC, LAT
I
n the United States, the incidence of sports-related concussion is estimated at 300,000 per year. Although, the
majority of athletes who experience a concussion are
likely to recover, an as yet unknown number of these
individuals may experience chronic cognitive and neurobehavioral difficulties.
Gwinnett Medical Center’s Sports Medicine Program has a
vision to improve the standard of care for athletes suffering
concussions. For the past four years, the hospital provided
Gwinnett County High Schools with a new tool to manage
head injuries. This tool is the ImPACT (Immediate Post-concussion Assessment and Cognitive Testing) program. The
program was implemented on May 1, 2008, and has since
managed 1,800 concussions while enrolling 19,000 youth
athletes in its program. This program is provided at no cost
to the athletes.
ImPACT has proven invaluable in the proper management of
sports concussion should an athlete sustain a concussion or
traumatic brain injury. The program is used by more than 400
high schools nationwide, collegiate, and professional levels of
sport. It includes a 20-minute, pre-season baseline test that athletes take on a computer to measures neurocognitive function,
such as brain processing, speed, memory, and visual motor
skills. ImPACT assesses crucial functions of the brain known
to be affected by concussion thus it correlates with quantifiable
deficit patterns post injury. These changes can be measured
objectively over time allowing for accurate awareness of the
injury’s severity as well as assist proper medical care through
each stage of recovery until the athlete is fully healed.
In the event of a concussion during the season, the athlete
would take the ImPACT test again and post-concussion data
is compared to the baseline data to help determine the presence and severity of the injury. Under the direction of a team
certified athletic trainer or physician, the athlete usually takes
the test several times in the days following injury to help determine recovery progress, demonstrate when the athlete’s
neurocognitive function has returned to pre-injury scores, and
determine when it is safe for the athlete to return to sports.
Although, the majority of athletes who experience a concussion
are likely to fully recover, some experience cognitive, and neurobehavioral difficulties related to recurrent injury. Such symptoms may include chronic headaches, fatigue, sleep difficulties,
personality change (e.g., increased irritability, emotionality),
10 GSMM
sensitivity to light/noise, dizziness, and deficits in short-term
memory, problem-solving, and general academic functioning.
This constellation of symptoms is referred to as “Post-Concussion Syndrome” and can be quite disturbing for an athlete
or their family. In some cases, such difficulties can be permanent and disabling. In addition to Post-Concussion Syndrome,
suffering a second blow to the head while recovering from an
initial concussion can have catastrophic consequences as in
the case of “Second Impact Syndrome,” which has led to approximately 30-40 deaths over the past decade.
Given these outlined concerns and difficulties in managing
concussion, individualized, and comprehensive management
of concussion is needed for full recovery. At the forefront of
proper concussion management is the implementation of
baseline and/or post-injury neurocognitive testing. Such evaluation can help to impartially 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 named the “cornerstone” of proper concussion management by an international
panel of sports medicine experts. ImPACT is a user-friendly
computer-based testing program specifically designed for the
management of sports-related concussion. The instrument
is designed based on approximately 10-years of Universitybased, grant-supported research.
GMC Recommendations for Concussion Care:
1. No adolescent with a concussion should continue to play or
return to a game after sustaining a concussion.
2. An individual sustaining a concussion should cease doing any
activity that causes the symptoms of a concussion to increase.
3. School attendance and activities may need to be modified.
(Time off from school, reduced homework, or rest breaks during the day)
4. Neuro-cognitive testing is an important component for the
management of concussions.
5. No athlete should return to contact competitive sports until
they are symptom free – both at rest and with exercise - and
have normal neuro-cognitive testing.
6. All sports and health education programs should teach
students the specific signs and symptoms of concussions.
Instructors must emphasize the serious consequences of ignoring concussion symptoms and the consequences that will
occur if concussions are not properly treated.
NO
Incident occurs.
Is a concussion recognized?
ATC sets up MD referral
ATC and Athlete complete ImPACT
Post Injury testing 24-72 hours.
MD
Appointment
Coordinated care between Physician, Parents, School,
ATC & Coach
CRITERIA:
A. Asymtomatic @ rest
AND w/ cognitive
exertion (mental
exertion in school)
AND
B. Within normal range
of baseline on postconcussion ImPACT
testing AND
C. Written clearance
from MD (athlete must
be cleared for
progression to activity
by an MD other than
Emergency Room MD)
Is Athlete
ready for non-contact
activity?
NO
YES
NO
Stepwise RTP Progression beginning with light noncontact activity progressing to full non-contact exertion.
Symptoms
Recur?
YES
NO
Repeat ImPACT & Refer
Baseline?
YES
Full Return to Play
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Specializing in Insurance and Risk Management for the Healthcare Providers throughout the Southeast
The Importance
of the Properly
Fitted Mouthguard
in Athletics
/// By: Jeremy R. Smith MD
Proper
Football
Helmet
Fitting
/// By: Sam Hadaway ATC, CSCS
T
hese days, concussions are the topic at the forefront
of almost any sports medicine lecture or debate. The
increased incidence of closed head injuries in contact
sports, such as football, combined with an improved
understanding of the epidemiology and long-term effects of concussions, has the sports medicine community looking for answers and reevaluating current methods of concussion
management. It is our responsibility as parents, coaches, and
sports medicine professionals to ensure that everything possible
is done to protect our athletes against the effects of concussion.
Although there is an inherent risk of injury with any sport, the risk
of sustaining a head injury can be substantially reduced by taking
proper preventative measures. Proper use of mouth guards and
coaching emphasis on correct blocking and tackling techniques
have already proven to be effective means of guarding against
concussion. This article intends to highlight another simple, yet
effective, way of protecting athletes that is commonly overlooked
or under appreciated by coaches and athletes: Proper Helmet
Fitting. According to a recent news release by the American Orthopaedic Society for Sports Medicine, “Athletes wearing properly fitted helmets, as reported by team Certified Athletic Trainers,
were 82% less likely to experience loss of consciousness (LOC)
with a concussion.”
Helmet fitting should be done by a trained coach, equipment
manager, or ideally by the team’s Certified Athletic Trainer. Perform the following steps sequentially with careful attention paid to
details while fitting the athlete.
12 GSMM
Step 1: Inspect the general condition of the helmet. Make note
of any obvious defects. Confirm that the helmet bears a current
National Operating Committee on Standards for Athletic Equipment (NOCSAE) certification sticker. Discontinue use of unsuitable helmets until reconditioned.
Step 2: Ask the athlete about any previous medical history of
concussion. Establish the type of helmet worn by the athlete in
the past.
Step 3: Using a cloth tape measure, begin at the side of the head
and wrap around one inch above the eyebrow and around the occipital lobe to record head circumference. This measurement is
used to determine proper helmet size.
Step 4: Select helmet style and fit to the athlete. This is based
on athlete’s position, comfort, and personal preference. However,
proper fit should supersede style or preference. Use manufacturer’s guidelines to fit the selected brand of helmet.
Step 5: The chinstrap is designed simply to keep the helmet in
place while playing. The chinstrap should not be used to adjust
the fit of the helmet. Make sure the chinstrap cup is aligned with
the center of the chin. Adjust and buckle front or high straps followed by back or low straps with equal tension on the straps.
Step 6: Check Fit
Crown Pressure- push down on the helmet with interlocked hands.
If properly fitted, the pressure should be distributed evenly around
the head. The helmet should not shift or slide down on the nose.
Lateral Grip- place hands on each side of helmet and ask the
athlete to hold the head still. Gently try to force the helmet side to
side. The facial skin should bunch up and helmet should not slide
across the face.
Vertical Grip- Again place hands on side of the helmet and ask
athlete to hold the head still. Gently roll helmet forward and backward. The skin on the forehead should move. The helmet should
not shift or slide down on the nose.
Make sure athlete understands that the helmet should fit snug
and is given an opportunity to ask questions and give input regarding fit of the helmet.
Step 7: Maintenance
Examine the helmet weekly. Report any damage or change in fit
to the team the equipment manager or Certified Athletic Trainer.
Air pressure should be adjusted as needed.
Repair broken snaps or wobbly facemasks immediately.
For a further details and to see specific standards set by the National Operating Committee on Standards for Athletic Equipment,
please visit www.nocsae.org.
A
re you an athlete or player? Perhaps you are a trainer, a coach, or a
medical professional that works with
young athletes? Chances are you
would like to know what the best protection possible for teeth is against
sports injury. While it is impossible
to eliminate all dental related sports
injuries, a custom fabricated mouthguard can reduce the risk.
Dental Injuries in sports are quite prevalent and can be quite costly. Almost one-third of all dental injuries are due to sports related
accidents. During a single athletic season, athletes have a one
in 10 chance of suffering a facial or dental injury. Tooth injury will
usually result in permanent disfigurement to the most visible upper front teeth. Estimates show that over a lifetime, dental costs
associated with a tooth that is knocked out and not replanted can
be as much as $20,000 (more than 25 times the cost of a custom
mouthguard). The chances of tooth damage increases by sixty
times if a guard is not worn during sports activity.
There are many benefits of a properly fitted and worn mouthguard. Guards prevent an estimated 200,000 injuries in high
school and college football. It allows an athlete to compete more
competitively and perform with more confidence. A mouthguard
can reduce the risk of cuts, bruising, and disfigurement to the
mouth, teeth, and face. A guard can reduce the chance of teeth
being fractured or lost. Research also shows that a mouthguard
can prevent neck injury.
Perhaps the biggest benefit of a mouthguard is its ability to help reduce the chance of concussion, as well as jaw fractures and dislocations. If there is not adequate cushioning of the jawbones, they
can be pushed into the base of the skull and even the brain cavity.
This dangerous blow can disrupt brain function and activity causing
a concussion as well as other skull damage. A custom fabricated
guard made by a dentist will cover all posterior teeth comfortably
with a predicted and consistent prescribed thickness to properly
separate the teeth from impact to the jaw. The custom mouthpiece
acts as a “spacer” by holding the lower jaw away from the base of
the skull. This limits the chance of obtaining a concussion via a
direct blow to the jaw via the chin. A mouthguard, in combination
with properly fitted protective headgear and chinstraps, will allow
for the utmost protection from dangerous head trauma.
The American Dental Association recommends custom made
mouthguards that have individual layers of plastic that are formed
under pressure to create a device that better protects teeth. This
Photo courtesy of
ShockDoctor.com
custom laminated guard is superior in fit and protection to the traditional ‘boil and bite’ guards that are sold in retail stores. This
type of appliance can prevent or dramatically lessen the impact
of concussive forces and other trauma to the lips, cheeks, gums,
tongue and mouth when worn in conjunction with a facemask and
helmet.
Pressure laminated mouthguards are more effective because they
can be altered depending on the needs of the athlete and the type
of sport in which each athlete participates. Light, medium, heavy,
and super heavy guards can be fabricated depending upon the
number of layers added. The thinnest type of appliance can be
used for smaller kids who don’t yet need the full protection of an
older athlete. Light guards are used for lower impact sports, such
as wrestling, volleyball, mountain biking and motocross. Medium
guards, or the universal mouth guard, would be suitable for the
majority of sports such as, soccer, rugby, basketball, softball, rollerblading, skating and skateboarding. Heavy impact appliances
are often used for baseball, football, racquetball, martial arts, or
boxing. Super heavy guards are best suited for competition that
involves extremely heavy impacts or that use rackets or sticks (ice
hockey, field hockey, street hockey, or kickboxing).
Mouthguards for younger players may offer a greater challenge
as far as being fitted for the guard. With rapidly changing teeth,
and possibility of the child having braces or some form of orthodontics taking place, it is especially important to have a custom
laminated guard that a dental professional can provide.
Lastly, to make mouthguard wear a bit more appealing, they can
be created in different colors to match those of athletes’ schools.
Colored guards are also preferred over clear ones because they
can be seen clearly by coaches, referees, or umpires who monitor
their use.
The role of trainers, coaches, medical professionals, and parents
is to encourage that mouthguards be worn for all sports and recreation activities when there is a chance for facial injury. Guards
should also be worn during practice and training sessions. We
have to remember the long term effects of concussions as well as
lost teeth in teens. Tooth loss is forever and a concussion has far
reaching effects on the brain. With a proper custom mouthguard
you will have more choice, more protection, and more comfort.
For further product specific details, please visit the websites of
nationally recognized mouth guard companies:
ShockDoctor www.shockdoctor.com
Gladiator Mouth Guards www.customgaurds.com
Protech Dent www.protechguards.com
GSMM 13
Rachel HavensFrom Darkness
into Light
/// By: Paige Havens
S
unday, November 6, 2011 was a crisp
fall morning that held the promise of a
great day of soccer. It was a weekend
like hundreds before it, but little did we
know that in a few short hours life as we
knew it was about to change.
Our 14-year-old daughter Rachel has
played soccer since she was 4 years old. She truly has no
memory of a time when she didn’t play. As an aggressive defender, she sees to it that few get past her and when they do,
they usually have to go through her. That’s exactly what happened that November day.
Rachel and an opponent went head-to-head about 5 minutes
into the game and both fell to the ground. It was a play like so
many - really uneventful, so I thought. Rachel lay there for a
few seconds and appeared to need a moment to catch her
breath. She stood and signaled she was fine to play on. She
tackled, she headed, and never let up. Little did we know the
storm brewing inside her.
When the whistle blew at the half, she went to the sideline. As she
began to cool down, the world came crashing in. Her head began
to pound, her vision blurred and everything began to spin. Before
she knew it she struggled to stand or speak. She told the coach
she wasn’t feeling well and requested someone sub in for her.
I knew something was wrong when she didn’t take her place
on the field. When I reached the bench Rachel did not know
who I was. All she could say was, “Please help me. My head.
My head.” As I looked into her eyes I saw the most horrifying
blank stare. Her eyes were far too dilated and she was shaking. We quickly made our way to GMC-Duluth.
Dr. Carlton Buchanan was on duty and he was able to help
get enough information from Rachel to piece together what had
happened. She had hit her head on the ground and blacked
out for a few seconds in that hit early in the game. Shock and
adrenaline had kept her going but when she stopped at half
time her body felt the impact of the injury. As she faded in and
out of consciousness there was no doubt she was badly concussed. After a CAT scan confirmed no bleeds, we were released to go home with a packet of information about specialists to follow-up with in the week to come.
14 GSMM
We were blessed to be referred to Dr. Mathew Pombo of Georgia Sports Medicine in Duluth. Dr. Pombo assessed Rachel’s
status quickly with the help of the IMPACT test. He took the time
to educate us on the latest trends in concussion care and outlined our plan of action. As a soccer player himself, Dr. Pombo
earned instant credibility with Rachel and we set the goal to have
Rachel back in full form for high school soccer tryouts in January.
The first few weeks were horrible. Our family lived in darkness
because her eyes were so sensitive to light. Rachel missed
two weeks of school because she simply could not function
through the pain and symptoms that consumed her. Her IMPACT scores continued to drop. Rachel’s attempts to keep current academically took a tremendous toll. It took everything
she had to push through and complete the fall semester. Unfortunately every day she pushed through set her back and
delayed her recovery.
Winter break was a welcome relief. With the ability to rest
often and control cognitive stimulation, some symptoms began
to subside, but the headache never relented. After Christmas,
Dr. Pombo was ready to test Rachel’s ability to handle physical
activity. He introduced us to Crystal Frazier, team trainer at
Peachtree Ridge High School. Crystal began to work one-onone with Rachel. After only three days of very light activity, the
symptoms came rushing back. Rachel’s brain would not tolerate any physical activity and there was no way to push it heal
any faster, We learned to take life one day at a time.
As tryouts drew closer, Rachel’s recovery slowed and depression set in. For months now Rachel had been removed from
all the things she loved to do. When she returned to school
for spring semester her brain hit overload again and all of the
symptoms came back with a vengeance. The headache continued to reign in her head and the empty stare returned. We
were back at square one.
Rachel missed another two weeks of school. We had to put
special academic accommodations in place to enable her to return. It took weeks for her to resume a full schedule again. The
hardest part was educating faculty and staff about how to care
for and support a concussed student. We joked that Rachel
needed a cast on her head so everyone would remember she
was still broken and needed time and help to heal.
From Darkness into Light <<<
In mid-January when we determined she would NOT be
cleared for team tryouts, it totally devastated Rachel. On the
eve of tryouts Rachel was struck with a condition called Conversion Disorder that left her paralyzed from the waist down
for 14 hours. The next day she was hit with a severe anxiety
attack that left her gasping to breath and hyperventilating to the
point that it looked like she was seizing. While physically there
was nothing wrong, the emotional trauma brought on extreme
physical symptoms that were very real. The concussion had
now broken her spirit.
We had to find a way to get Rachel back to the game she
loves so much before this totally consumed her. Dr. Pombo and
Crystal worked quickly to formulate a plan. The coaches allowed Rachel to attend practices and games, serving as team
manager. Being on the sidelines allowed her to feel a part of
the team and be close to the action again. Crystal monitored
her daily and gave us the assurance we needed to let go a little.
It was the perfect medicine!
By mid-February we saw marked improvement in her IMPACT
scores. In early March Rachel began to slowly ease back into
physical activity and this time her brain embraced it. On day
130 her headache broke and after 132 days of being sidelined,
Rachel was cleared to play soccer again. Though only a few
games were left in the season, it was a glorious moment when
Rachel stepped out onto that field as a Peachtree Ridge Lion
for the first time.
Today the sparkle is back in Rachel’s eyes and the bounce
is back in her step. Though she has no memory of November
6th and continues to struggle with concentration, anxiety and
blurred vision, she has clearly moved from darkness back into
the light. It was a long, painful journey. In those five months we
worked hard to find blessings in the brokenness and trusted
that God would use this struggle for His purpose.
Since November we’ve come to know many who have been
down this same path. We are blessed that our Rachel made
a full recovery and can return to the pitch. Some are not so
lucky. We are so very grateful to those at Gwinnett Medical
Center that we met along our way. Their expertise, support and
encouragement kept us going on the darkest days. We now
appreciate the importance of comprehensive concussion care
and the need for baseline testing. We’ve become big champions of concussion awareness, education, legislation and
standards of care. Gwinnett Medical Center’s Sport Medicine
Program defines quality concussion care in this region. Know
without a doubt GMC that your “impact” on this community is
immeasurable!
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Recognition and
On-Field Treatment
of Heat Illnesses
and Heat Stroke
/// By: Stephanie H. Hsu, MD
H
eat related illness and deaths are rising,
even though they are preventable. Heat
illness occurs when the body’s ability to cool
itself is overwhelmed. Even healthy athletes
can be affected by heat illness in seemingly
cool weather. Heat stroke, a severe form of
heat illness, is one of the three leading causes of death in athletes.
Heat related illnesses range from mild to life-threatening; including
heat cramps, heat exhaustion, and exertional heat stroke.
Contrary to popular belief, heat illness does not always present in a progressive manner. Early recognition and rapid cooling
can reduce both the morbidity and mortality associated with heat
illnesses, especially from heat stroke. Signs and symptoms of
heat illness can be subtle and easy to miss if athletes, coaches,
and medical staff do not maintain a high level of awareness and
monitoring before, during, and after physical activity. Prevention
of heat related illness starts early, with individual athlete risk evaluation and pre-event preparation for all athletes.
Body heat increases during exercise and is regulated internally,
and simply, by sweat evaporation. Although these can occur in
any environment, during hot and humid conditions the risk of heat
related illnesses sharply increases due to lessened sweat evaporation and therefore, the body’s ability to cool. Heat illness occurs
worldwide and in almost every sport. High intensity, long duration, or heavy exertional exercise athletes are especially at risk.
Heat associated heat cramps/muscle cramping is a mild form
of heat related illness and usually responds well to on site treatment. They are painful spasms of the skeletal muscles, most
often occurring in prolonged, strenuous exercise and are common in sports such as tennis, football, and distance running. Most
spasms last from 1 to 3 minutes, but can last in series up to 6 or 8
hours. Exercise associated muscle cramping does not usually involve excessive hyperthermia, but is usually the result of fatigue,
body water loss, sodium and/or electrolyte depletion, and/or internal body regulation that fails with exhaustion. Muscle cramps
that occur in the heat are often thought to present differently,
without warning, due to the large amount of sodium and water losses
involved. Multi-day tournaments, two-a-day practices, and multiple
event competitions also increase the risk of exertional heat cramps.
Rest, supervised prolonged stretching of the muscles to full
length, and fluid replacement of electrolytes and salt (sports drinks
and salty snacks, in addition to water) should be started immediately. If cramps are severe and do not respond to first line treatment, intravenous normal saline can also provide rapid relief. Any
persistence of cramping beyond these measures may require the
administration of monitored medications by a physician. Prevention of heat associated cramps includes encouragement of fluid
and salt balance, increased intake with heat acclimatization, and
increased care with athletes prone to cramps or at risk.
Heat exhaustion the most common heat related illness in the
active population. The range of signs and symptoms are broad
and non-specific as the body is having difficulty compensating for
the fatigue, dehydration, and increased temperature with activity.
Athletes may be pale, shaky, sweating excessively, have chills,
headaches, or are nauseated or dizzy. Those suffering from heat
exhaustion can exhibit irritability, decreased muscle coordination,
vomiting or diarrhea. The skin can feel cool and sweaty, while the
pulse is light and fast, and breathing becomes quick and shallow.
Treatment for heat exhaustion begins with moving the athlete
to a cool, shaded or air conditioned area and removing excess
clothing. Elevate the athlete’s legs while they are lying down.
Start oral fluids rehydration, again with a sports type drink, and
closely monitor vital signs and mental status. Cool mist sprays,
sponge baths, ice packs, or cool water immersion may be initiated. The true measurement to discriminate between heat exhaustion and the more deadly heat stroke is a rectal temperature greater than 104° F. Any athlete that experiences mental or
cognitive changes, or does not respond to initial steps should be
treated more emergently and medical staff should be contacted
immediately. Athletes with more severe symptoms of heat exhaustion should always be rested and referred to a physician for
further evaluation.
Signs and Symptoms
Treatment
Heat Cramps
Muscle spasms, cramping, normal body temperature
Heat
Exhaustion
Thirst, fatigue, weakness, nausea, dizziness, extreme sweating. dilated pupils, headache, pale, cool,
moist skin, mild confusion, and vomiting
Stop exercise, massage, stretch cramping muscle, Replace fluids
and electrolytes
Rest, cooling, and fluid and electrolyte replacement. If symptoms do
not quickly improve, the player should be taken to the emergency
room
Heat Stroke
Increased body temperature, dry hot skin, mental
Immediate transport to emergency room, rapid cooling, and fluid
status changes, constricted pupils, confusion, seizure, replacement.
loss of consciousness
16 GSMM
Heat Illnesses and Heat Stroke <<<
the rectal temperature decreases to normal and the athlete’s
Heat stroke is a preventable, possibly life threatening degree
mental status and function has returned to normal. Athletes sufof heat illness. It can be categorized as classic or exertional heat
stroke. Classic heat stroke patients present with dry, hot, and
fering from heat stroke recognized early, treated, and recovering within the first hour are shown to have the best recovery
flushed skin as opposed to the sweaty, pale, and cool skin of an
rates. Heat stroke can be fatal or with longstand consequences,
athlete suffering from exertional heat stroke. Heat stroke occurs
when the core body temperature becomes too high (>104° F), and
and when presents with cardiovascular collapse and shock, can
can cause central nervous system disturbances and multiple orprogress to multiple organ failure. These cases all require imgan system failure.
mediate, higher level medical treatment and follow up.
The risk of exertional heat stroke is greatest when the wet bulb
Immediate recognition of exertional heat stroke is paramount to
globe temperature is greater than 82° F, and high intensity and/
survival. Signs and symptoms are often vague, including both
cognitive and physical changes. Cognitive signs and symptoms
or strenuous exercises lasts for greater than 1 hour. Athletes
include dizziness, confusion, disorientation, apathy, inappropriat greatest risk are those not heat acclimated, have inadequate
ate or unusual behavior, delirium or irritability. Physical signs
physical fitness, a pre-exisiting illness, are dehydrated, take
certain medications or alcohol, have sunburn or skin disease,
and symptoms include headache, clumsiness, loss of balance,
sleep deprivation, age >40, obesity, or a previous history of
loss of muscle function and collapse, severe fatigue, hyperventilation (fast breathing), nausea, vomiting, diarrhea, seizures, or
heat illness.
even coma. Therefore, any change in the usual performance or
As heat illnesses can be life-threatening yet preventable, prepersonality of an athlete should be evaluated especially in hot,
ventative measures, along with being able to recognize, evaluate, and treat an athlete with rapid response is essential in sports
humid conditions.
today. From heat cramps, to heat exhaustion, and even heat
Exertional heat stroke is a life threatening emergency, and
stroke, immediate treatment with proper methods can be simply
requires immediate, knowledgeable treatment. Whole body
learned and effective. Coaches, athletic trainers, and medical
cooling, by cold water and ice immersion provide the fastest
staff should recognize signs and symptoms of heat illness early
cooling rates and lowest mortality and morbidity from heat
to prevent more serious injury or mortalilty. Much of the emphastroke. Or, rapid rotation of ice water soaked towels to the
sis on heat illnesses should be pre-event, with proper heat achead, trunk, and extremities with ice packs to the neck, axillae, and groin also provides a reasonable, but slower, rate
climatization, hydration, preparation and monitoring to keep our
athletes safe and prevent heat illnesses from occurring.
of body cooling. These methods should be continued untilB:8.875 in
T:8.375 in
S:7.625 in
www.euflexxa.com
ExerciseRelated
Heat Illness
/// By: Brian Morgan, MD
E
xercise-related heat illness (ERHI)
or “heat injury” happens when intense exercise is done in high temperature and high humidity, causing hyperthermia, or elevated body
temperature. Heat related injuries
occur frequently in sports. They
range in severity from very mild
to very severe. It is estimated that
heat related illnesses are to blame for over 400 deaths per
year in the US. In high school football players alone, more
than 120 players have died from heat related illnesses between
1960 and 2009. The annual death rate was about one per year
from 1980 to 1994, but rose to almost 3 per year during the
next 15 years. In 2011 alone, at least seven high school football
deaths were attributed to heat illness. This increase in death
rate is likely due to several factors: increased competition/ intensity of workouts, increasing temperatures, year-round play
with minimal time to rest or acclimate to the conditions, and
larger players (nearly 95 percent of the 58 players who died
between 1980 and 2009 were overweight or obese).
Fortunately, these injuries are 100% preventable. No player
should ever die of a heat related illness. The most important
factor in prevention is education. Players, trainers, and coaches must be aware and on the lookout for the telltale signs and
symptoms of heat related illness. These signs and symptoms
occur along a spectrum of increasing severity as the illness progresses from heat cramps to heat exhaustion to heat stroke.
Heat cramps are the least serious form of heat related illness, characterized by muscle spasms caused by physical
activity in hot weather. Heat cramps are painful and can be
an early symptom of heat stroke. Body temperature remains
normal with this condition. Treatment includes rest, stretching,
massage, and fluid and electrolyte replacement.
Heat exhaustion is a precursor to heat stroke and is identified when systemic symptoms occur. Early symptoms include
increased thirst, fatigue, weakness, nausea, dizziness, and
extreme sweating. Later, more severe symptoms occur, including dilated pupils, headache, pale, cool, moist skin, mild
confusion, and vomiting. Treatment includes rest, cooling, and
fluid and electrolyte replacement. If symptoms do not quickly
improve, the player should be taken to the emergency room.
Untreated heat exhaustion can rapidly deteriorate into a lifethreatening condition known as heat stroke, which occurs
when the body loses the ability to regulate its temperature.
18 GSMM
Sweating stops and the temperature spirals out of control
to dangerous levels over 104 deg. Other symptoms include
dry hot skin, mental status changes, constricted pupils, confusion, seizure, loss of consciousness, and if not treated
promptly, death. Treatment involves immediate transport to
emergency room, rapid cooling, and fluid replacement.
Risk factors for heat related illnesses should be recognized
and avoided if possible. These include very young or very
old athletes, obesity, strenuous exercise in very hot or humid
weather, and wearing heavy clothes or layers in hot weather.
Alcohol use and medications such as amphetamines, antihistamines, tranquilizers, and anticholinergics can also be risk factors.
Prevention is the key to avoid heat related illnesses. It is important to avoid strenuous activity in extreme heat. Practices
should only be held when the heat index is in a safe level (temperature charts can be used to determine). Practices can be
held in the morning or evening or indoors. Players should wear
cool, loose clothing and stay well hydrated with frequent rest
breaks. Helmets and pads can be removed. Air conditioners,
fans, and water should be used on the sidelines. Temperature
monitoring, helmet sensors (102.5), heat tables, and urine
charts can be used to monitor the conditions and the players.
In summary, unlike most sports injuries caused by unavoidable contact, heat related injuries are completely preventable. Common sense and hydration are crucial to prevent
and treat heat related illness. Early recognition of signs and
symptoms is critical to avoid more serious conditions. Finally, it is very important to seek medical attention early if
symptoms worsen or do not improve with early treatments.
Exertional
Heat Illness
Readiness Plan
/// By: Jay Pearson ATC, LAT
H
eat illness is inherent to physical activity and its
incidence increases when ambient temperature
surges and relative humidity rises. Athletes who
begin training in the late summer such as football,
soccer, and cross-country are at higher risk for
heat injury because of when their season occurs. This group
has a higher incidence of injury and treatment data for exertional
heat-related illness than athletes or sports that participate during
winter and spring seasons as seen in national surveillance studies. Although extreme environmental conditions associated with
late summer climates explain the higher injury rates, organizations
should anticipate their yearly reoccurrence with a comprehensive
plan to recognize, treat, and mostly prevent these injuries.
Preparing athletes for activity in spring or summer heat can be
a formidable challenge but with an outlined game plan including
essential components, the challenge is reduced while proactively
addressing the need. Several steps are essential for a successful plan for prevention, recognition, and treatment. These recommendations can be modified based on the environmental conditions of the venue, the specific sport, proficiency, and individual
considerations to maximize safety. The effective plan should include a preseason activity screening for all athletes, a specific
emergency action plan, an acclimatization plan, an on-site cool
zone, and implementing activity protocols.
All athletes must complete a preseason physical screening and
be cleared by a medical physician before beginning any activity.
This screening consists of a detailed medical history, blood pressure, pulse, height and weight, functional orthopedic screen, and
listening to the function of the heart and lungs. Once an athlete
passes the screening, is considered normal by the physician without the presence of positive findings, the athlete is ready to start
progressing into activity.
The medical team has the responsibility to set-up preseason
exams and produce documentation of any underlying conditions
that may cause an increased risk for injury. This system should
include identification of any person with a previous history of heat
injury or conditions that predispose to an injury. After athletes are
identified with an increased risk to heat injury, they are closely
monitored and examined before, during, and after activity for the
reoccurrence or exacerbation of symptoms. Other documented
disposing medical conditions that may need probing during the
screening are malignant hyperthermia, neuroleptic malignant
syndrome, arteriosclerotic vascular disease, scleroderma, cystic
fibrosis, sickle cell trait, and rhabdolyomyolisis.
20 GSMM
Exertional Heat Illness Readiness Plan<<<
New Georgia High School Association mandates, starting
in 2012, focus specifically on acclimatization and exposure
times in hot environments. In Georgia, football practice may
begin five consecutive weekdays prior to August 1. In the first
five days of practice for any student, the practice shall not last
longer than 2 hours, and the student cannot wear protective
gear except for a helmet and mouthpiece. All activity times for
a session are measured from the time the players report to the
field until they leave the field. In addition, beginning August 1,
all students may practice in full pads and two times in a single
calendar day only when he or she participated in five conditioning practices wearing no protective gear other than a helmet
and mouthpiece before being allowed to practice in full pads.
If multiple workouts are held in a single day:
After preseason screenings, the most critical step in addressing heat illness is to develop an Emergency Action Plan
(EAP). All medical personnel, coaches, managers, and others
regularly working with the team must be familiar with the EAP
as well as practice it annually. Administrators should review
and approve the EAP on a yearly basis preceding activity.
The EAP should include phone numbers and directions to
venue locations, situation specific steps including communication, define venue access, chain of command, type of
care administered on-site, who administers the care, available equipment, and guidelines for activating EMS or hospital
transport. The EAP is a roadmap defining roles and steps of
care if an emergency arises.
Used as a tool for treatment and designated in the EAP, a cool
zone is utilized when a heat emergency occurs. The cool zone
is a predestinated space away from direct sunlight and away
from the adverse environment. Usually, the cool-zone is a tent
or shelter where an athlete exhibiting signs and symptoms of
heat illness is treated. This area should have water, sodium
with electrolyte -containing drinks, ice, ice towels, and submersion cold tubs to aggressively cool down and rehydrate the athlete. The athlete must be removed from activity and the hot
environment for medical assessment with treatment following.
When heat stress is recognized, aggressive and immediate
whole-body cooling is the key to controlling it. 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
such as muscle, the heart, or the brain. Due to superior cooling
rates, immediate whole-body cooling (cold-water immersion),
is one of the best treatments for EHS and should be initiated
within minutes post-incident. It is a known best practice to cool
first, transport second if onsite rapid cooling and adequate
medical supervision are available.
Gradual acclimatization is the most effective method of
avoiding heat stress. A good preseason-conditioning program that started prior to the beginning of activity in the heat
is highly recommended. All organizations must monitor the
progressive exposure to heat in the first 10 to 14 days of activity. During the first five to eight days of activity in the heat, 80
percent acclimatization can be achieved based on a two-hour
practice session in the morning and a two-hour session in the
evening. The sessions will be broken down into patterns of
work to rest ratios starting with 20-minute intervals.
• No single session may last longer than 3 hours
• The total amount of time in the two practices
shall not exceed 5 hours
• There must be at least a 3-hour time of rest between sessions
• There may not be consecutive days of two-a-day
practices. All double-session days must be followed
by a single-session day or a day off
A fundamental practice in developing your heat plan is monitoring the athlete before, during, and after activity. One of
the best tools for prevention of exertional heat injury is body
weight monitoring. Weight monitoring allows one to measure
and track two aspects of each player’s weight: the amount
lost after each activity session and the amount gained before
the next activity session. The process is simple. The athlete
weighs in dry clothes before and after practice, documents
the total weight on a chart, and weights are compared to determine participation in future activity sessions. A loss of 3 to
5 percent or three pounds of total body weight compared to
the original weight should result in suspension of all participation until the weight has been regained. The minimum exclusion should equal one activity session. All exclusions should
be documented in the individual athlete’s medical file and
then communicated to coaches as a potential risk for injury.
Finally, the heat plan needs a way to monitor and measure
the environmental risk for potential injury. The wet bulb globe
temperature (WBGT) is the most recognized measurement
for determining necessary precautions for activity in hot or
humid environments. Inexpensive electronic meters that
measure the WBGT are readily available and widely used in
athletics because of how easily they evaluate surroundings.
All medical teams should have training and access to an electronic device that can calculate the environmental WBGT. To
perform reliable, reproducible results, the measuring device
should be used in a constant, open area unshielded from the
sun or wind, and performed by the same person every time.
The ground below should be either grass or gravel. Asphalt
and concrete surfaces readings are not appropriate because
they cannot be consistently reproduced.
All school WBGT recommendations and cutoffs are based
on set GHSA guidelines. Commercial weather stations may
not routinely report WBGT readings, but instead report heat
indexes in an attempt to quantify the effect which high levels
of heat and humidity have on the human body. Heat index is
calculated differently from the WBGT and should not be used
for determining heat stress risks.
Readings should be taken on the field thirty minutes prior
to activity and every thirty minutes once activity has started. These readings should be documented on a monitoring
form, noting any modifications made to activity. Modifications can be made accordingly based on the activity and
work to rest patterns during scheduled activity by coaches.
A final consideration in dealing with heat stress in athletics
is nutritional education. Educating the athlete on proper fluids and foods to consume before, during, and after practice
will help contribute in efforts to prevent injury. Eating and
drinking appropriately will help keep the athlete functioning
properly for activity levels. During activity, water needs to
be present at all drill stations, ad-libitum, and pre scheduled
breaks built into practice schedules. Providing water at all
times to the athletes will help maintain hydration levels during practice times while reducing the accumulative effects
of heat exposure.
The athletic medical team should establish on-site emergency plans for their venues and any high-risk athletes they
monitor. The primary goal of athlete safety is addressed
with a well-developed plan to evaluate and treat athletes if
an injury occurs. Even with a heat-illness prevention plan
that includes medical screening, acclimatization, conditioning, environmental monitoring, and suitable practice adjustments, heat illness can and does occur. Athletic trainers,
other health providers, and coaches must be prepared to
respond in a pragmatic way integrating known tactics to
limit the occurrence and severity of heat-associated illnesses. Doing so will raise awareness for prevention while
creating a safer environment for athletics.
GHSA Mandated Activity Guidelines Using WBGT
Under 82.0
Normal activities--Provide at least three separate rest
breaks each hour of minimum duration of 3 minutes each
during workout
82.0 - 86.9
Use discretion for intense or prolonged exercise; watch
at-risk players carefully; Provide at least three separate
rest breaks each hour of a minimum of four minutes duration each
87.0 - 89.9
Maximum practice time is two hours. For Football: players restricted to helmet, shoulder pads, and shorts during practice. All protective equipment must be removed
for conditioning activities. For all sports: Provide at least
four separate rest breaks each hour of a minimum of four
minutes each
90.0 - 92.0
Maximum length of practice is one hour, no protective
equipment may be worn during practice and there may
be no conditioning activities. There must be 20-minutes of
rest breaks provided during the hour of practice
Over 92.1
No outdoor workouts; Cancel exercise; delay practices
until a cooler WBGT reading occurs
GSMM 21
>>>Exertional Heat Illness Readiness Plan
Home Care
Basics
Heat injuries can occur during physical activity or any hot
weather activity when an individual:
• Is not properly hydrated or acclimatized
• Is exposed to extreme heat or has prolonged exposure
• Has on heavy clothing or equipment
• Has had a previous heat injury or is exposed for multiple
days in a row
• Has used alcohol, certain dietary supplements,
over the counter drugs or prescription drugs
• Is ill, fatigued, or not rested
Prevention
• Participation in preseason screenings to identify history or
risk factors
• Appropriate conditioning
• Body weight monitoring
• Protocol for environmental monitoring and activity modification
plan based on WBGT
• Properly designed rest/work cycles with access to fluids
• Adequate acclimatization plan and use of uniforms/equipment
• Reduction or elimination of recurrent practice sessions with
exposure to heat
• Have an EAP with steps to recognize, limit, and control heat
related risk factors
Better Results
Recommendations for Coaches
• Have a specific hydration/rehydration protocol in place with water
access ad-libitum
• Wear light color/weight practice gear and clothes
• Know the early signs and symptoms of a heat illness
• Plan for and use a cooling station
• Have an explicit emergency action plan in place monitoring and
addressing heat injuries
More people continue to choose BenchMark Physical Therapy
because we help them feel better, faster.
We deliver
• Orthopedic Manual Therapy, proven to be more
effective than exercise alone
• A commitment to advanced certification for all of our therapists. In
fact we have more advanced certified therapists than any other
provider in this area.
• Our one-to-one, personalized approach
The difference... we get better results.
So much so that we’re proud to publish our patient outcomes, which
consistently exceed national standards.
What are you looking for in a
physical therapy provider?
Guardian
Guardian Home Care (an AccentCare company) provides services for homebound patients
in over twenty counties here in Georgia and has
been serving the Gwinnett county area for the
last eight years. Our offices provide skilled nursing and rehabilitation services in the home.
With over 100 years of combined experience,
our team of physical therapists are prepared to
meet the various needs of our patients with a
compassionate and interdisciplinary approach.
We have partnered with several orthopedic
groups to develop specific protocols to better
serve patients with hip, knee, spine, and shoulder surgeries.
In addition, our Orthopedic Program was developed using the most current and evidencebased interventions. The Program begins with
a physical therapy visit within 24 hours of discharge from the hospital. This visit includes
a home safety assessment to ensure that you
have a safe environment in which to recover.
Your therapist will recommend a home exercise
program, help to manage your pain, and answer
questions about your recovery. We will also
ensure that a caregiver in your home will have
adequate training regarding how to assist you
safely and when to call our office for help. Your
rehabilitation will be based on a combination of
your patient assessment and your physician’s
specifications and guidelines for treatment.
Guardian Home Care also has a Fall Prevention program for those patients who may have
experienced a fall or a decline in function in their
home for various reasons such as arthritis, balance disorders, dizziness, or lack of strength or
mobility. Our clinicians will again use a multidisciplinary approach to address and decrease
risk factors for falls, which are the leading cause
of hospitalization due to injury.
“In home therapy is a more comfortable and
easier setting to treat patients” says Cathy Hedrich, one of Guardian’s physical therapists.
“Every situation is different and every patient is
different. There’s always something new. When
working in a patient’s home, you can really see if
there are any safety hazards. I enjoy being able
to guide a patient to their maximum potential
so they can meet their personal goals whether
that’s getting back to working in their garden,
cooking, or even taking care of their pets.”
Guardian is very passionate about patient
care. We value the trust of our referring physicians and look forward to continuing to serve
those in need.
GSMM 23
Preventing Dehydration
During Summer Activities
MVPs of Sports Medicine
THE SPORTS MEDICINE & ORTHOPAEDIC
INSTITUTE OF GWINNETT
/// By: Ann Dunaway Teh, MS, RD, LD
S
www.dunawaydietetics.com
ummer is upon us, which for many means
playing outside, enjoying the pool or lake to
cool off and traveling. While hydration, or the
provision of adequate fluid to bodily tissues, is
important at all times of the year, it is especially
important during the summer months with the
high heat and humidity common in Georgia.
Water is the most important nutrient in the body. The average
person’s body weight is 60% water, though it fluctuates and can
depend on a number of factors including age, gender and body
composition. Having adequate fluids in the body is necessary
for a number of bodily functions, but especially for the cardiovascular system and body temperature control mechanisms.
Hydration is a key component of being physically active. Being properly hydrated during physical activity improves performance whereas dehydration can lead to muscle cramping, increased body temperature, increased heart rate and therefore
impaired athletic performance. Furthermore, being dehydrated
puts one more at risk for other serious heat-related illnesses
such as heat exhaustion or heat stroke. People, and particularly children, are often already dehydrated before symptoms
appear so prevention is critical.
The ideal beverage for staying hydrated is water. Cool or cold
water is more palatable and encourages people to drink more
than warm or room temperature water. Some people prefer to
have some flavor in their water, no matter the temperature. Adding flavor can make it easier to consume water. Rather than buying expensive flavored waters or powdered packets, which are
also usually laden with sugar or artificial sweeteners, make your
own flavored water with fruit such as sliced oranges. An alternative to sliced fruit is sliced cucumber in water, particularly if you
or a neighbor has a garden overflowing with it. Sliced cucumber
in water is a refreshing treat that even children will enjoy. Another
way to encourage children to drink more water is by having a
special water bottle or a fun straw to drink out of just for water.
Sports drinks are appropriate to use after 60 minutes of exercise in hot and humid conditions. Sports drinks are specially
formulated to provide carbohydrates and electrolytes and replace fluids lost during exercise. Do not confuse, however,
sports drinks and energy drinks. They are not the same thing.
Energy drinks are primarily sugar and caffeine. The American
Academy of Pediatrics recommends that children and adolescents do NOT drink energy drinks. Caffeinated beverages can
be dehydrating as well since they cause people to urinate more
often, thereby speeding up fluid loss.
24 GSMM
How do you know how much to drink? Thirst is not a good indicator of hydration status. Often by the time a person is thirsty, it is too
late. The color of a person’s urine, on the other hand, is a good
indicator of hydration status. You should have at least one urination a day that is clear to light yellow in color. Keep in mind that
some vitamin supplements, however, can affect urine color. Here
are some guidelines for drinking before, during and after exercise:
Before: drink 12 – 20 ounces 2 – 3 hours
before exercise; children should drink 4
to 8 ounces of fluid 30 minutes before
activity
During: For adults, drink 6 – 12 ounces
every 15 – 20 minutes during exercise
and for children and adolescents, drink
5-9 ounces every 15 – 20 minutes during exercise (the more the child weighs,
the more he/she needs to drink)
After: For adults, drink 24 ounces for
every 1 lb of weight lost through sweat
and for children and adolescents drink 16 ounces for every 1 lb
of weight lost through sweat. To determine weight lost, weigh
yourself before and after exercise. You want to try to rehydrate
within 2 hours after exercise.
In addition to drinking fluids, eating foods such as fruits and
vegetables is another way to help stay hydrated on a daily basis. Fruits and vegetables naturally have a high water content.
Most Americans do not eat enough fruits and vegetables as it is,
so this is just one more reason to include them with meals and
snacks or pre- and post-exercise. According to the Centers for
Disease Control and Prevention, in 2009 only 32.5% of adults
ate two or more servings of fruit a day and only 26.3% of adults
ate three or more servings of vegetables a day. The 2009 Youth
Risk Behavior Surveillance revealed that only 33.9% of high
school aged students ate two or more servings of fruit a day and
only 13.8% ate three or more servings of vegetables a day (2).
During the summer months, fresh fruits and vegetables are
plentiful and usually lower in price than other times of year. Including a fruit or a vegetable every time you eat will not only
ensure you are eating enough in a day, but it will help with fluid
balance. Watermelon, for instance, is a summer favorite that
is rich in nutrients, low in calories, and high in water content. It
makes a great snack or a dessert. Some other ways to enjoy
the season’s bounty to help keep cool and top off your fluid
tanks are with chilled soups, such as gazpacho. Making your
own fruit smoothies with yogurt, milk and frozen fruit is another
way to boost your daily fluid intake as well as provide good protein and carbohydrates, necessary after strenuous exercise.
Don’t get sidelined this summer by the heat. The best hydration plan is one that you do every day. Drink plenty of fluids, especially water, as well as eat your fruits and vegetables to stay
ahead of the competition and the debilitating effects of being in
the sun for long periods of time.
References
1.Centers for Disease Control and Prevention. State indicator report on fruits and vegetables, 2009. US Department of Health
and Human Services, CDC; 2009. Available at http://www.fruitsandveggiesmatter.gov/indicatorreport. Accessed May 17, 2012.
2.Centers for Disease Control and Prevention. Youth risk behavior surveillance, United States 2009. Surveillance Summaries,
June 4, 2010. MMWR 2010;59(No. SS-5). Available at http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Accessed May 17, 2012.
BUFORD
985
85
GWINNETT COUNTY
85
DULUTH
23
120
LAWRENCEVILLE
141
NORCROSS
20
Johns Creek Offices
SNELLVILLE
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GET BACK IN THE ACTION.
Choose Atlanta’s sports medicine specialists.
About 85% of sports-related concussions go unrecognized and untreated.
Because of this, the Sports Medicine Program at Gwinnett Medical CenterDuluth is leading the way in concussion management by offering the
Immediate Post-Concussion Testing (ImPACT) program to every high school
athlete in Gwinnett.
As the only hospital in Georgia to offer ImPACT countywide, our goal is
to reduce the chance of follow-up concussions, thus helping our student
athletes’ performance both on the field and in the classroom.
To learn more about our program, visit gwinnettsportsmed.com.
Gwinnett Medical is a proud recipient of the
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