THE MANAGEMENT OF
WITH SPECIFIC PROVISIONS FOR
CHILDREN AGED 5-17 YEARS
AFL CONCUSSION WORKING
GROUP SCIENTIFIC COMMIT TEE
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 1
For trainers, first-aid providers,
coaches, club officials and parents
›› Any concussed player must not be
allowed to return to school or return to
sport before having a medical clearance.
Summary
›› Head impacts can be associated
with serious and potentially fatal
brain injuries.
›› In the early stages of injury, it is often
not clear whether you are dealing with
a concussion or there is a more severe
underlying structural head injury. For
this reason, the most important steps in
initial management include:
1. Recognising a suspected concussion;
2. Removing the player from the game;
and
3. Referring the player to a medical
doctor for assessment.
›› Any player who has suffered a
concussion or is suspected of having a
concussion must be medically assessed
as soon as possible after the injury and
must NOT be allowed to return to play in
the same game/practice session.
›› There should be an accredited first
aider at every game and the basic
rules of first aid should be used
when dealing with any player who is
unconscious or injured.
THE MANAGEMENT OF
For children and
adolescents (players aged
5-17 years)
WITH SPECIFIC PROVISIONS FOR
CHILDREN AGED 5-17 YEARS
›› S
ymptom evaluation in the child often
requires the addition of parent and/or
teacher input.
›› T
he child is not to return to
football, or other sport, until
he/she has successfully returned to
school/learning, is symptom-free,
and has received medical clearance.
However early introduction of limited
physical activity is appropriate, as long
as symptoms do not worsen.
›› It is reasonable for a child to miss
a day or two of school after concussion,
but extended absence from school
is uncommon.
This document has been published by the AFL as a position statement on the
management of concussion in Australian Football. It is based on guidelines developed
by the AFL Concussion Working Group Scientific Committee.
The guidelines should be adhered to at all times. Decisions regarding return to play after
concussive injuries should only be made by a medical doctor with expertise in concussion.
June, 2017
G AV I N D AV I S , M I C H A E L M A K D I S S I , P E T E R H A R C O U R T,
PAT R I C K C L I F T O N , D AV I D M A D D O C K S , PAU L M C C R O R Y
J U N E 2 017
Background
Introduction
In considering the best practice
management of sport-related
concussion (SRC), the priority remains
the short- and long-term welfare of
the player.
Since 2001, five international meetings
have been held to address key issues in
the understanding and management of
SRC. Following each of these meetings,
a summary has been published to
“improve the safety and health of
athletes who suffer concussive injuries
during participation in sport”. The most
recent conference was held in Berlin
in October 2016. The summary from
the Berlin meeting provides the most
up-to-date knowledge on SRC. It also
outlines the current best practice
management guidelines.(1)
In general, children require a
different approach from adults
because their brains are developing,
and they need to continue learning
and acquiring knowledge. As such,
the priority is not just player
welfare and return to sport, but a
critical element is return to school
and learning.
4 Background
What is concussion?
Head impacts can be associated with
serious and potentially fatal brain injuries.
“Traumatic brain injury” is the broad term
used to describe injuries to the brain
that are caused by trauma. The more
severe injuries usually involve structural
damage, such as fractures of the skull
and bleeding in the brain. Structural
injuries require urgent medical attention.
Concussion typically falls into the milder
spectrum of traumatic brain injury
and is thought to reflect a temporary
disturbance in brain function, rather than
structural damage or any permanent
injury to the brain.
Concussion is caused by trauma to
the brain, which can be either direct
or indirect (e.g. whiplash injury). When
the forces transmitted to the brain
are high enough, they can "stun" the
nerves and affect the way in which
the brain functions. This results in a
range of observable signs (such as
lying motionless on the ground, blank
or vacant look, balance difficulties or
motor incoordination, etc) or symptoms
reported by the player (such as headache,
blurred vision, dizziness, nausea, balance
problems, fatigue and feeling “not
quite right”). Other common features of
concussion include confusion, memory
loss and reduced ability to think clearly
and process information. It is important
to note that loss of consciousness is
seen in only 10-20 per cent of cases of
concussion in Australian Football. That
is, the footballer does not have to lose
consciousness to have a concussion.
How long does it usually
take to recover from
concussion?
The recovery process following
concussion varies from person to
person and injury to injury. Most cases
of concussion in Australian Football
recover within 10-14 days of injury,
however, in a small number of cases,
recovery may take weeks to months. In
general, children and adolescents take
longer to recover, and typically take up
to four weeks to recover.
The presence of concussion is
occasionally associated with a neck
injury, and may be difficult to assess
in the early period after head trauma.
All concussed athletes should be
considered to have a neck injury until
medically cleared.
How common is concussion
in Australian Football?
Concussion is a relatively common
injury in Australian Football. At the
elite level, the overall rate of concussion
is 6-8 per 1000 player hours (one
approximately every three matches
for a team of 22 players).
What are the potential
complications following
concussion?
A number of complications can occur
following concussion. These include:
›› Higher risk of further concussion or
other injuries on return to play;
›› P
rolonged symptoms (lasting >
14 days in adults; >four weeks in
children/adolescents);
›› S
ymptoms of depression and other
psychological problems; and
›› Long-term damage to brain function.
It is important to be aware that
any knock to the head can result in
severe brain swelling, particularly
in younger players.
In general, complications are not
common. The risk of complications
is thought to be increased by allowing
a player to return to sport before
they have recovered. This is why it is
important to recognise concussion,
and keep the player out of full-contact
training and games until they have
fully recovered.
Concussion symptoms can cause
problems with memory and information
processing, which interferes with the
child’s ability to learn in the classroom.
It is for this reason that a child is not to
return to school until medically cleared
to do so.
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 5
Management guidelines
for suspected concussion
Presence of any concussion symptoms or signs
(e.g. stunned, confusion, memory problems, balance
problems, headache, dizziness, not feeling right)
Remove from the ground.
Assess using Concussion Recognition Tool
5th Edition (CRT5)2
Presence of any red flags
(e.g. neck pain, loss of consciousness, confusion,
vomiting, worsening headache)
NO
YES
Call for ambulance and
refer to hospital
Do not allow player
to return to play
Refer to medical
doctor for assessment
(at venue, local
general practice or
hospital emergency
department)
Figure 1. Summary of the management of concussion in Australian Football.
*Note: for any player with loss of consciousness, basic first aid principles should be used (i.e. airways,
breathing, CPR ...). Care must also be taken with the player’s neck, which may have also been injured in
the collision. The unconscious player must not be moved by anyone other than a medical professional
or ambulance officer. An ambulance should be called, and these players transported to hospital
immediately for further assessment and management.
6 Management guidelines for suspected concussion
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 7
A. Game-day management
The most important steps in the
initial management include:
1. Recognising a suspected concussion.
2. Removing the player from the game.
3. Referring the player to a medical
doctor for assessment.
Recognising a suspected
concussion
›› Visible clues of suspected concussion
Any one or more of the
following visual clues can indicate
a possible concussion:
›› Loss of consciousness
or responsiveness
›› Lying motionless on
ground/slow to get up
›› Vomiting
›› Seizure or convulsion
›› Unsteady on feet/balance
problems or falling
over/incoordination
›› Grabbing/clutching of head
›› Dazed, blank or vacant look
›› Confused/not aware of plays
or events
›› Facial injury
›› Loss of consciousness, confusion and
memory disturbance are all classical
features of concussion. The problem
8 A. Game-day management
with relying on these features to
identify a suspected concussion is that
they are not present in every case.
Symptoms reported by the player
that should raise suspicion of
concussion include:
››
››
››
››
››
››
››
››
››
››
››
››
Headache
Nausea or feel like vomiting
Blurred vision
Balance problems or dizziness
Feeling “dinged” or “dazed”
“Don’t feel right”
Sensitivity to light or noise,
More emotional or irritable
than usual
Sadness, nervous/anxious
Neck pain
Feeling slowed down, feeling like
in a fog
Difficulty concentrating or
difficulty remembering
›› T
ools such as the CRT5 (see page 14)
should be used to help identify
a suspected concussion.
›› It is important to note, however, that
brief sideline evaluation tools (such
as the CRT5), are designed to help
identify a suspected concussion.
They are not meant to replace a
more comprehensive medical
assessment and should never be
used as a stand-alone tool for the
management of concussion.
›› Currently no commercially available
tools (impact sensors, balance apps,
etc) can be relied upon to either
diagnose or exclude a concussion.
›› A pre-game checklist should be printed
and provided to trainers and other
staff involved in the match-day care
of players. The checklist should be
kept with the Concussion Recognition
Tool 5th Edition (CRT5). The checklist
should include contact details for:
a)Local general practices;
b)Local hospital emergency
departments; and
c)Ambulance services (000).
›› The pre-game checklist can also
be provided to trainers and medical
staff of the away team, who are
likely to be less familiar with local
medical services.
Removing the player
from the game
›› T
he basic rules of first aid should be
used when dealing with any player
who is unconscious or injured.
›› Immobilisation of the neck in a
cervical collar by a qualified first
aid provider may be required. An
appropriate sized collar should be
available at every game.
›› R
emoving the conscious player from
the game allows the first aid provider
time and space to assess the player
properly. Assessment should take place
in a distraction-free environment, such
as the change rooms.
›› A
ny conscious player with a suspected
concussion must be removed from the
game and not be allowed to return
to play in the same game or training
session. Do not be swayed by the
opinion of the player, trainers, coaching
staff, parents or others suggesting
premature return to play. (See section
below right for management of the
unconscious player).
Referring the player
to a medical doctor
for assessment
›› M
anagement of head injury is difficult
for non-medical personnel. In the
early stages of injury, it is often not
clear whether you are dealing with a
concussion or there is a more severe
underlying structural head injury.
›› F
or this reason, ALL players with
a suspected concussion need an
urgent medical assessment (with
a registered medical doctor). This
assessment can be provided by a
medical doctor present at the venue,
local general practice or hospital
emergency department.
›› If a doctor is not available at
the venue, then the player
should be transferred to a local
general practitioner or hospital
emergency department.
›› It is useful to have a list of local
doctors and emergency departments
near the ground at which the game or
training session is taking place. This
resource can be determined at the
start of each season (in discussion
with the local medical services).
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 9
Management of an
unconscious player and
when to refer to hospital
Basic first aid rules should be used
when dealing with any unconscious
player (i.e. danger, response, airway,
breathing, circulation).
Care must be taken with the player’s
neck, which may have also been injured
in the collision.
›› In unconscious players, the player
must only be moved (on to the
stretcher) by qualified health
professionals, trained in spinal
immobilisation techniques.
›› If no qualified health professional is
on site, then do not move the player –
await arrival of the ambulance.
›› If the unconscious player is wearing
a helmet, do not remove the helmet,
unless trained to do so.
›› Urgent hospital referral is necessary
if there is any concern regarding
the risk of a structural head or
neck injury.
›› Overall, if there is any doubt, an
ambulance should be called and the
player referred to hospital.
Urgent transfer to hospital
is required in a player with any
of the following:
›› Neck pain or tenderness
›› Double vision
›› Weakness or tingling/burning in
the arms or legs
›› Severe or increasing headache
›› Seizure or convulsions
›› Loss of consciousness
›› Deteriorating conscious state
›› Vomiting
›› Increasing restlessness,
agitation or combative
behaviour
B. Follow-up management
›› A
ny concussed player must not
be allowed to return to school or
return to sport before having a
medical clearance.
›› I n children, return to learn and
school should take precedence
over return to sport.
›› In every case, the decision regarding
the timing of return to training should
be made by a medical doctor with
experience in managing SRC.
›› In general, a more conservative
approach (i.e. longer time to return to
sport) is used in cases where there
is any uncertainty about the player’s
recovery (“if in doubt, sit them out”).
›› Extra time to complete
assignments/tests
Return to school
Concussion may impact on a child‘s
ability to learn at school. This must be
considered, and medical clearance is
required before the child may return
to school.
It is reasonable for a child to miss a
day or two of school after concussion,
but extended absence from school
is uncommon.
10 A. Game-day management
The child will progress through the
return to school program provided
that there is no worsening of their
concussion-related symptoms. If any
particular activity worsens symptoms,
the child will abstain from that activity
until it no longer causes worsening of
their concussion-related symptoms. Use
of computers and internet should follow
a similar graduated program, provided
that it does not worsen concussionrelated symptoms. This program should
include communication between
the parents, teachers and health
professionals and will vary from child
to child. The return to school program
should consider:
›› Quiet room to complete
assignments/tests
›› Avoidance of noisy areas such as
cafeterias, assembly halls, sporting
events, music class
›› Frequent breaks during class,
homework, tests
›› No more than one exam/day
›› Shorter assignments
The child’s doctor should help them get
back to school after a few days.
›› Repetition/memory cues
In some children, a graduated return
to school program will need to be
developed for the child. Additional
management by a paediatric
neuropsychologist may assist in more
difficult cases.
›› Reassurance from teachers that
student will be supported through
recovery through accommodations,
workload reduction, alternate forms
of testing
›› Use of peer helper/tutor
›› Later start times, half-days,
only certain classes.
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 11
All schools are encouraged to have
a concussion policy that includes
education on SRC prevention and
management for teachers, staff,
students and parents, and should offer
appropriate academic accommodations
and support to students recovering
from SRC.
The child is not to return to
football, or other sport, until
he/she has successfully returned to
school/learning, is symptom-free,
and has received medical clearance.
However, early introduction of limited
physical activity is appropriate, as long
as symptoms do not worsen.
If there are any doubts, management
should be referred to a qualified health
practitioner, expert in the management
of concussion in children.
Return to play
›› Players should not return to football
and other sports until their concussionrelated symptoms have resolved and
they have successfully returned to
school/university/learning.
›› Players should be returned to
football/sport in a graduated fashion.
›› When returning to play/sport, the
player should follow a stepwise,
medically managed exercise
progression, with increasing amounts
of exercise. For example:
›› Daily activities that do not
provoke symptoms
›› Light aerobic activity (e.g.
walking, swimming or stationary
cycling) – can be started
24-48 hours after symptoms
have recovered
›› Light, non-contact training drills
(e.g. running, ball work)
›› Non-contact training drills
(i.e. progression to more complex
training drills, may start light
resistance training. Resistance
training should only be added in
the later stages)
Concussion
is a relatively
common injury
in Australian
football. At the
elite level the
overall rate of
concussion is
6-8 per 1000
player hours
›› Full contact training – only after
medical clearance
›› Return to competition (game play)
›› In this example, it would be typical
to have 24 hours (or longer) for each
step of the progression.
›› If any symptoms worsen while
exercising, the player should go back
to the previous step. Resistance
training should be added only in the
later stages.
›› If the player is symptomatic for more
than 10-14 days (four weeks in
children/adolescents), then review by
a medical practitioner, expert in the
management of SRC, is recommended.
12 B. Follow-up management
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 13
CONCUSSION RECOGNITION TOOL 5 ©
To help identify concussion in children, adolescents and adults
RECOGNISE & REMOVE
Head impacts can be associated with serious and
potentially fatal brain injuries. The Concussion
Recognition Tool 5 (CRT5) is to be used for the
identification of suspected concussion. It is not
designed to diagnose concussion.
STEP 1: RED FLAGS — CALL AN AMBULANCE
If there is concern after an injury, including
whether ANY of the following signs are observed
or complaints are reported, then the player
should be safely and immediately removed from
play/game/activity. If no licensed healthcare
professional is available, call an ambulance for
urgent medical assessment:
• Neck pain or
tenderness
• Double vision
• Weakness or
tingling/burning in
arms or legs
• Severe or increasing
headache
• Seizure or convulsion
Remember:
• In all cases, the basic
principles of first aid
(danger, response,
airway, breathing,
circulation) should
be followed.
• Assessment for a
spinal cord injury
is critical.
• Loss of
consciousness
•Deteriorating
conscious state
•Vomiting
•Increasingly
restless, agitated
or combative
• Do not attempt to
move the player (other
than required for
airway support) unless
trained to so do.
• Do not remove a
helmet or any other
equipment unless
trained to do so safely.
If there are no Red Flags, identification of possible
concussion should proceed to the following steps:
STEP 2: OBSERVABLE SIGNS
Visual clues that suggest possible concussion include:
• Lying motionless on the • Blank or vacant look
playing surface
• Balance, gait
• Slow to get up after a
difficulties, motor
direct or indirect hit to
incoordination,
the head
stumbling, slow
laboured movements
• Disorientation or
confusion, or inability
• Facial injury after
to respond appropriately
head trauma
to questions
14 B. Follow-up management
Helmets
STEP 3: SYMPTOMS
• Headache
• “Pressure in head”
• Balance problems
• Nausea or vomiting
• Drowsiness
• Dizziness
• Blurred vision
• Sensitivity to light
• Sensitivity to noise
• Fatigue or low energy
• “ Don’t feel right”
• More emotional
• More irritable
• Sadness
• Nervous or anxious
• Neck pain
• Difficulty concentrating
• Difficulty remembering
• Feeling slowed down
• Feeling like “in a fog“
STEP 4: MEMORY ASSESSMENT
(IN ATHLETES OLDER THAN 12 YEARS)
Failure to answer any of these questions (modified
appropriately for each sport) correctly may suggest
a concussion:
• “ What venue are we
at today?”
• “Which half is it now?”
• “Who scored last in
this game?”
• Not be sent home
by themselves. They
need to be with a
responsible adult.
• Not drive a motor
vehicle until cleared to
do so by a healthcare
professional.
The CRT5 may be freely copied in its current form
for distribution to individuals, teams, groups and
organisations. Any revision and any reproduction in
a digital form requires approval by the Concussion
in Sport Group. It should not be altered in any way,
rebranded or sold for commercial gain.
Mouthguards
There is no definitive scientific
evidence that helmets prevent
concussion or other brain injuries
in Australian Football.
Helmets may have a role in the
protection of players on return to play
following specific injuries (e.g. face or
skull fractures).
Overall, however there is insufficient
scientific evidence to make a
recommendation for the use of helmets
for the prevention of concussion in
Australian Football.
“What team did
you play last
week/game?”
• “Did your team win
the last game?”
Athletes with suspected concussion should:
• Not be left alone
initially (at least
for the first 1-2 hours).
• Not drink alcohol.
• Not use recreational/
prescription drugs.
Role of helmets & mouthguards
in Australian Football
Mouthguards have a definite role in
preventing injuries to the teeth and face
and for this reason they are strongly
recommended at all levels of football.
Mouthguards should be worn for all
games and training sessions.
Dentally-fitted laminated mouthguards
offer the best protection. ‘Boil and
bite’ type mouthguards are not
recommended for any level of play as
they can dislodge during play and block
the airway.
There is some preliminary scientific
evidence that mouthguards may
prevent concussion or other brain
injuries in Australian Football.(3)
References
1. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion
in sport-the 5th international conference on concussion in sport held in Berlin,
October 2016. Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097699
2. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool
5th Edition (CRT5). Br J Sports Med 2017 doi: 10.1136/bjsports-2017-097508
3. Emery CA, Black AM, Kolstad A, et al. What strategies can be used to
effectively reduce the risk of concussion in sport? Br J Sports Med 2017
doi:10.1136/ bjsports-2016-097452.
ANY ATHLETE WITH A SUSPECTED
CONCUSSION SHOULD BE IMMEDIATELY
REMOVED FROM PRACTICE OR PLAY
AND SHOULD NOT RETURN TO ACTIVITY
UNTIL ASSESSED MEDICALLY, EVEN IF THE
SYMPTOMS RESOLVE
© Concussion in Sport Group 2017
THE MANAGEMENT OF CONCUSSION IN AUSTRALIAN FOOTBALL 15
Australian Football League
AFL House
140 Harbour Esplanade
Docklands VIC 3008
GPO Box 1449
Melbourne VIC 3001
visit afl.com.au
Download PDF
Similar pages