Concussion and Heat Issue

SPORTS MEDICINE MAGAZINE








Concussion and Heat Issue

SUMMER 2012

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>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 /// 13>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 MVP’s of Sports Medicine

Letter from the Editor <<<

Concussions and heat illness may not only cause an im-mediate decrease in athletic performance, but more im-portantly, 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 train-ers 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 en-vironment to athletes’ health and their overall ability to perform at the desired level. Heat illness and death is preventable and rec-ognizing 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 ad-equately understand the severity of these injuries will help us to ensure the safety of our athletic programs and the long-term well-being 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]

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Gary A. Levengood, MD>Chief of Sports Medicine, Gwinnett Medical Center>Orthopedic and Sports Medicine Consultant to the GHSA>Founder and Owner, Sports Medicine South, LLC>Editor, Gwinnett Sports Medicine Magazine

4 GSMM

The CDC defines concussion as” A complex pathophysiological process affecting the brain, induced by traumatic biomechani-cal 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 struc-tural neuroimaging findings (i.e. CT, MRI). Concussions re-sult 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 vari-able 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 acci-dents. 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 atten-tion at the time of the injury, but they later report symptoms of headache, dizziness or difficulty remembering or concen-trating. 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 syn-drome, 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. Adoles-cent athletes who participate in contact sports are at an in-creased risk for concussion and second impact syndrome.

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 learn-ing – 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 be-lieve 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 li-censed high school coaches and Athletic Directors in the Gwinnett County be re-quired to complete continuing education units yearly with competency testing on the recognition and treatment of concus-sions in order to maintain licensure.2. The GMCSMC recommends that each high school develop and maintain a concus-sion action plan that identifies a healthcare professional to respond to concussions dur-ing games and practices, that develops edu-cation opportunities (i.e. concussion symptom cards) for coaches/athletic staff (administra-tors, counselors, and school nurses) in the implementation of the action plan. 3. The GMCSMC recommends the educa-tion of teachers during pre-school planning sessions and education packets to make them aware of the difficulties kids with con-cussions can have in the classroom to bet-ter prepare them for providing and imple-menting academic accommodations and special need pathways.

Recognition:1. The GMCSMC supports the use of certified athletic train-ers (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 en-sure better recognition and guidance with initiation of concus-sion 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 boost-er 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 re-moved 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 test-ing 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 testing

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GMCSMC Concussion Position Statement <<<

GMCSMC Concussion Posi t ion StatementBy: Matthew Pombo MD, Mark Cullen MD,

Gary Levengood MD, and Yvonne Satterwhite, MD

[email protected]

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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 dis-ruption 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 nor-mal and in most concussions are not indicated.

Concussion Recognition/// By: Mark C. Cullen, MD

What are the signs and symptoms of a concussion? Signs and symptoms of concussion can show up right af-ter an injury or may not appear until hours or days after the injury. Most concussions occur without a loss of conscious-ness. If your child reports or demonstrates one or more of the symptoms of concussion listed below, seek medical atten-tion 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 assignmentsSymptoms reported by your child or teenThinking/Remembering:• Difficulty thinking clearly, Difficulty concentrating or remem-bering, Feeling more slowed down, Feeling sluggish, hazy, foggy, or groggyPhysical:• 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, NervousSleep:• Drowsy, Sleeping less or more than usual, Trouble falling asleep

When to seek immediate medical attention: • 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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A 16 year old, Ju-nior High S c h o o l

soccer player leaves her feet to head a ball, an opponent clips her knees, and she falls to the ground unprotect-ed, striking her head to the ground. Though there is no loss of con-sciousness or mental status changes, the young girl perceives some disturbing symp-toms 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, ath-letes, etc.) to better recognize the signs and symptoms of a concussion to increase our ability to diagnose them, and there-fore, 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 regard-ing 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

/// By: Mathew Pombo, MD

8 GSMM

injury, and the specific brain areas that are affected. The peri-concussion 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 nau-sea, 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 man-agement, 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 cur-rent 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 wors-ens, 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 forcognitive 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 tar-geted to prevent their grades from suffering during their re-covery. Only 40% of athletes with a concussion are better in 1 week, and only 80-90% are better at 3-4 weeks, so a concus-sion 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 neurocog-nitive-testing program to assist in our athletes’ safe return to participation. The program utilizes the ImPACT test, a comput-erized 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 respec-tive 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 oc-curs, the athlete is held out of any physical activity and is fol-lowed 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 pro-gressively 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 guide-lines mandate that an athlete be asymptomatic at rest, as-ymptomatic with exertion, and have normal neurocognitive testing. Old Grading Scales (Cantu, etc.) and AAN guide-lines are no longer a valid treatment algorithm in the Sports concussion arena. Concussions can have devastating ef-fects on grades and classroom function. Should a concus-sion be suspected it is irresponsible to play through it. Con-cussions 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.

point, could lead to a rare incidence of sudden death from in-tracranial bleeding or second impact syndrome (second blow to the head during a vulnerable phase during concussion re-covery 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, neurobe-havioral 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 train-ing) 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 com-plex-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 sleep-related symptoms and may or may not involve a loss of con-sciousness (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 RECOGNI-TION. The sideline presentation of an athlete with a concussion may vary widely with symptoms ranging from those that are ob-vious to subtle findings that may not be present until they return to school under cognitive loads. Many of these symptoms de-pend on the biomechanical forces involved, the severity of the Call today and discover the E2E difference!

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The Treatment of Concussions and Necessary Provisions

The Treatment of Concussions and Necessary Provisions <<<

10 GSMM

In the United States, the incidence of sports-related con-cussion 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 neu-robehavioral 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-con-cussion 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 ath-letes 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 pres-ence 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 de-termine 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 neu-robehavioral difficulties related to recurrent injury. Such symp-toms may include chronic headaches, fatigue, sleep difficulties, personality change (e.g., increased irritability, emotionality),

GMC’s ImPACT Program/// By: Tim Simmons, MHA, ATC, LAT

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-Con-cussion Syndrome” and can be quite disturbing for an athlete or their family. In some cases, such difficulties can be perma-nent 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 ap-proximately 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 eval-uation 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 “corner-stone” 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 University-based, 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 dur-ing 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 ig-noring concussion symptoms and the consequences that will occur if concussions are not properly treated.

GMC ImPACT POC Algorithm

Pre-season baseline testing completedStudent cleared to fully participate in athletics

Immediate removal from activity w/ any s/s of concussion

Incident occurs. Is a concussion recognized?

NO

YES

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.

ATC and Athlete complete ImPACT Post Injury testing 24-72 hours.

ATC sets up MD referral

MDAppointment

Coordinated care between Physician, Parents, School, ATC & Coach

Is Athlete ready for non-contact

activity?

Stepwise RTP Progression beginning with light non-contact activity progressing to full non-contact exertion.

NO

YES

CRITERIA:A. Asymtomatic @ rest AND w/ cognitive exertion (mental exertion in school) ANDB. Within normal range of baseline on post-concussion ImPACT testing ANDC. Written clearance from MD (athlete must be cleared for progression to activity by an MD other than Emergency Room MD)

Repeat ImPACT & Refer

SymptomsRecur?

Full Return to Play

Baseline?

NO

YES

YES

NO

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12 GSMM

These 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 ef-

fects of concussions, has the sports medicine community look-ing 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 Or-thopaedic Society for Sports Medicine, “Athletes wearing prop-erly 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. Per-form the following steps sequentially with careful attention paid to details while fitting the athlete.

Proper Football Helmet Fitting/// By: Sam Hadaway ATC, CSCS

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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 Equip-ment (NOCSAE) certification sticker. Discontinue use of unsuit-able 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 oc-cipital 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 manufac-turer’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 fol-lowed by back or low straps with equal tension on the straps.Step 6: Check FitCrown 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 back-ward. 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 re-garding fit of the helmet.Step 7: MaintenanceExamine 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 Na-tional Operating Committee on Standards for Athletic Equipment, please visit www.nocsae.org.

Are you an athlete or player? Per-haps 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 pro-tection 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 cost-ly. 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 up-per 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 mouth-guard. 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 re-duce the chance of concussion, as well as jaw fractures and dislo-cations. 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

The Importance of the Properly Fitted Mouthguard in Athletics/// By: Jeremy R. Smith MD

custom laminated guard is superior in fit and protection to the tra-ditional ‘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, roll-erblading, 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 ortho-dontics 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 rec-reation 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.comGladiator Mouth Guards www.customgaurds.comProtech Dent www.protechguards.com

Photo courtesy of ShockDoctor.com

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Sunday, 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 de-fender, she sees to it that few get past her and when they do, they usually have to go through her. That’s exactly what hap-pened 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 shak-ing. 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 con-cussed. After a CAT scan confirmed no bleeds, we were re-leased to go home with a packet of information about special-ists to follow-up with in the week to come.

We were blessed to be referred to Dr. Mathew Pombo of Geor-gia 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 out-lined 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 IM-PACT scores continued to drop. Rachel’s attempts to keep cur-rent academically took a tremendous toll. It took everything she had to push through and complete the fall semester. Un-fortunately 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-on-one with Rachel. After only three days of very light activity, the symptoms came rushing back. Rachel’s brain would not toler-ate 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 depres-sion 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 con-tinued 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 re-turn. 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.

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 Con-version 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 al-lowed 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 cham-pions 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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From Darkness into Light <<<

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Rachel Havens-From Darknessinto Light/// By: Paige Havens

Heat 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 pres-ent 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 eval-uation 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 evapo-ration and therefore, the body’s ability to cool. Heat illness occurs worldwide and in almost every sport. High intensity, long dura-tion, 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 treat-ment. They are painful spasms of the skeletal muscles, most often occurring in prolonged, strenuous exercise and are com-mon 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 in-volve excessive hyperthermia, but is usually the result of fatigue, body water loss, sodium and/or electrolyte depletion, and/or in-ternal 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 immedi-ately. If cramps are severe and do not respond to first line treat-ment, 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. Preven-tion 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 initi-ated. The true measurement to discriminate between heat ex-haustion and the more deadly heat stroke is a rectal tempera-ture 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 ex-haustion should always be rested and referred to a physician for further evaluation.

Heat stroke is a preventable, possibly life threatening degree of heat illness. It can be categorized as classic or exertional heat stroke. Classic heat stroke patients present with dry, hot, and flushed skin as opposed to the sweaty, pale, and cool skin of an athlete suffering from exertional heat stroke. Heat stroke occurs when the core body temperature becomes too high (>104° F), and can cause central nervous system disturbances and multiple or-gan system failure. Immediate recognition of exertional heat stroke is paramount to survival. Signs and symptoms are often vague, including both cognitive and physical changes. Cognitive signs and symptoms include dizziness, confusion, disorientation, apathy, inappropri-ate or unusual behavior, delirium or irritability. Physical signs and symptoms include headache, clumsiness, loss of balance, loss of muscle function and collapse, severe fatigue, hyperven-tilation (fast breathing), nausea, vomiting, diarrhea, seizures, or even coma. Therefore, any change in the usual performance or personality of an athlete should be evaluated especially in hot, humid conditions. Exertional heat stroke is a life threatening emergency, and requires immediate, knowledgeable treatment. Whole body cooling, by cold water and ice immersion provide the fastest cooling rates and lowest mortality and morbidity from heat stroke. Or, rapid rotation of ice water soaked towels to the head, trunk, and extremities with ice packs to the neck, axil-lae, and groin also provides a reasonable, but slower, rate of body cooling. These methods should be continued until

the rectal temperature decreases to normal and the athlete’s mental status and function has returned to normal. Athletes suf-fering from heat stroke recognized early, treated, and recover-ing within the first hour are shown to have the best recovery rates. Heat stroke can be fatal or with longstand consequences, and when presents with cardiovascular collapse and shock, can progress to multiple organ failure. These cases all require im-mediate, higher level medical treatment and follow up. The risk of exertional heat stroke is greatest when the wet bulb globe temperature is greater than 82° F, and high intensity and/or strenuous exercises lasts for greater than 1 hour. Athletes at greatest risk are those not heat acclimated, have inadequate physical fitness, a pre-exisiting illness, are dehydrated, take certain medications or alcohol, have sunburn or skin disease, sleep deprivation, age >40, obesity, or a previous history of heat illness. As heat illnesses can be life-threatening yet preventable, pre-ventative measures, along with being able to recognize, evalu-ate, and treat an athlete with rapid response is essential in sports today. From heat cramps, to heat exhaustion, and even heat stroke, immediate treatment with proper methods can be simply learned and effective. Coaches, athletic trainers, and medical staff should recognize signs and symptoms of heat illness early to prevent more serious injury or mortalilty. Much of the empha-sis on heat illnesses should be pre-event, with proper heat ac-climatization, hydration, preparation and monitoring to keep our athletes safe and prevent heat illnesses from occurring.

Heat Illnesses and Heat Stroke <<<

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Recognition and On-Field Treatment of Heat Illnesses and Heat Stroke

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Signs and Symptoms Treatment

Heat Cramps Muscle spasms, cramping, normal body temperature Stop exercise, massage, stretch cramping muscle, Replace fluids and electrolytes

Heat Exhaustion

Thirst, fatigue, weakness, nausea, dizziness, ex-treme sweating. dilated pupils, headache, pale, cool, moist skin, mild confusion, and vomiting

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 status changes, constricted pupils, confusion, seizure, loss of consciousness

Immediate transport to emergency room, rapid cooling, and fluid replacement.

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Exercise-related heat illness (ERHI) or “heat injury” happens when in-tense exercise is done in high tem-perature and high humidity, caus-ing 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/ in-tensity 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 coach-es 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 pro-gresses from heat cramps to heat exhaustion to heat stroke. Heat cramps are the least serious form of heat related ill-ness, 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 identi-fied when systemic symptoms occur. Early symptoms include increased thirst, fatigue, weakness, nausea, dizziness, and extreme sweating. Later, more severe symptoms occur, in-cluding 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 life-threatening condition known as heat stroke, which occurs when the body loses the ability to regulate its temperature.

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, con-fusion, 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, antihis-tamines, tranquilizers, and anticholinergics can also be risk factors. Prevention is the key to avoid heat related illnesses. It is im-portant to avoid strenuous activity in extreme heat. Practices should only be held when the heat index is in a safe level (tem-perature 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 unavoid-able contact, heat related injuries are completely prevent-able. 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. Fi-nally, it is very important to seek medical attention early if symptoms worsen or do not improve with early treatments.

Exercise-Related Heat Illness /// By: Brian Morgan, MD

Exertional Heat Illness Readiness Plan/// By: Jay Pearson ATC, LAT

Heat 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 stud-ies. 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 success-ful plan for prevention, recognition, and treatment. These recom-mendations can be modified based on the environmental condi-tions of the venue, the specific sport, proficiency, and individual considerations to maximize safety. The effective plan should in-clude 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 pres-sure, 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 with-out 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.

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 start-ed. These readings should be documented on a monitoring form, noting any modifications made to activity. Modifica-tions 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 flu-ids 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 dur-ing practice times while reducing the accumulative effects of heat exposure. The athletic medical team should establish on-site emer-gency 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, condition-ing, environmental monitoring, and suitable practice adjust-ments, 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 ill-nesses. Doing so will raise awareness for prevention while creating a safer environment for athletics.

GHSA Mandated Activity Guidelines Using WBGTUnder 82.0 Normal activities--Provide at least three separate rest breaks each hour of minimum duration of 3 minutes each during workout82.0 - 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 dura-tion each87.0 - 89.9 Maximum practice time is two hours. For Football: play-ers restricted to helmet, shoulder pads, and shorts dur-ing 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 each90.0 - 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 practiceOver 92.1 No outdoor workouts; Cancel exercise; delay practices until a cooler WBGT reading occurs

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After preseason screenings, the most critical step in ad-dressing 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 commu-nication, define venue access, chain of command, type of care administered on-site, who administers the care, avail-able 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 submer-sion cold tubs to aggressively cool down and rehydrate the ath-lete. 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 result-ing 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 pro-gram 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 activ-ity. 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.

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 condition-ing 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:• 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 moni-toring 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 de-termine 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 participa-tion until the weight has been regained. The minimum exclu-sion 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 elec-tronic 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

Exertional Heat Illness Readiness Plan<<<

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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.

Better Results

What are you looking for in a physical therapy provider?

BasicsHeat 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

>>>Exertional Heat Illness Readiness Plan Guardian Home Care (an AccentCare com-pany) 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 nurs-ing 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 shoul-der surgeries. In addition, our Orthopedic Program was de-veloped using the most current and evidence-based interventions. The Program begins with a physical therapy visit within 24 hours of dis-charge 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 Preven-tion program for those patients who may have experienced a fall or a decline in function in their home for various reasons such as arthritis, bal-ance disorders, dizziness, or lack of strength or mobility. Our clinicians will again use a multi-disciplinary 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 He-drich, 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 phy-sicians and look forward to continuing to serve those in need.

Guardian Home Care

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

THE SPORTS MEDICINE & ORTHOPAEDICINSTITUTE OF GWINNETT

•Academy Orthopedics - 3540 Duluth Park Lane, Sui te 220Duluth, Georgia - 770.271 .9857 - www.academyorthopedics .com

•Sports Medic ine South - 1900 Rivers ide Parkway Lawrencevi l le , GA 30043 -770.237.3475 - www.sportsmedsouth.com

•Georgia Sports Medic ine & Orthopaedic Surger y - 6340 Sugar loaf Parkway, Sui te 375Duluth, GA. 30097 - 770.814 .2223 - www.georgiasportsmedic ine.com

•Resurgens Orthopaedics - 6335 Hospital Parkway, Suite 302Johns Creek, GA 30097 - 404-575-4500 - www.resurgens.com

•Southern Orthopaedic Specia l ists - 771 O ld Norcross Road, Sui te 390Lawrencevi l le , GA 30046 - 678.957.0757 - www.sos-at lanta .com

•The Sports Medic ine & Orthopaedic Inst i tute of Gwinnett -3855 P leasant H i l l Road, Sui te 470 Duluth, GA 30096 - 770.813 .8888 - www.gwinnettsportsmedic ine.com

MVPs of Sports Medicine

LAWRENCEVILLE

DULUTH

NORCROSS

BUFORD

GWINNETT COUNTY

SNELLVILLE

85

23 120

85

985

141

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•Advanced Hand and Upper Extremity Surger y - 4255 Johns Creek Parkway. Sui te ASuwanee, GA 30024 - 678.608.1951 - www.ahuespc.com

Johns Creek Offices

Summer 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 cardio-vascular system and body temperature control mechanisms. Hydration is a key component of being physically active. Be-ing properly hydrated during physical activity improves perfor-mance whereas dehydration can lead to muscle cramping, in-creased 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 particu-larly 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. Add-ing flavor can make it easier to consume water. Rather than buy-ing 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 alterna-tive 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 ex-ercise in hot and humid conditions. Sports drinks are specially formulated to provide carbohydrates and electrolytes and re-place 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 adoles-cents 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.

Preventing Dehydration During Summer Activities

www.dunawaydietetics.com

/// By: Ann Dunaway Teh, MS, RD, LD

How do you know how much to drink? Thirst is not a good indica-tor 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 urina-tion 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 dur-ing 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 ba-sis. 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. In-cluding 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 pro-tein and carbohydrates, necessary after strenuous exercise. Don’t get sidelined this summer by the heat. The best hydra-tion plan is one that you do every day. Drink plenty of fluids, es-pecially 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. References1.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.

About 85% of sports-related concussions go unrecognized and untreated. Because of this, the Sports Medicine Program at Gwinnett Medical Center-Duluth 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 2012 Healthgrades® America’s 100 Best™ Hospitals

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Concussion and Heat Issue