If, after the evaluation noted above, the Club Physician determines that the Player is not diagnosed with concussion, the Player may return to play at the Club Physician's discretion. Evolving and delayed-onset symptoms of concussion are well documented and highlight the need to follow-up with a player after a suspected concussion regardless of a negative acute evaluation. Therefore, Club Medical Personnel shall follow-up with the Player 24 hours after an incident where there was a clinical suspicion of concussion to inquire whether any concussion symptoms have subsequently developed.
In situations where a clinical assessment has been conducted and the Club Physician determines that he or she does not have definitive information to either make or exclude a diagnosis of concussion, the diagnosis may be deferred and documented in the SCAT5 App. If a diagnosis of concussion is deferred, the Player shall not be returned to play and a follow-up clinical assessment, which at a minimum should include a complete SCAT5, must be conducted within 24 hours, at which point a definitive diagnosis shall be made or excluded.
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• Specifically, Players who are diagnosed with a concussion should undergo an initial, brief period of physical and cognitive rest (e.g., 24-48 hours).
• Players can then become gradually and progressively more exposed to activities (a "graded return-to-play progression") that do not provoke cognitive and physical symptoms (i.e., increased activity level should not bring on or worsen symptoms).
An example of a graded return-to-play progression is provided below. Generally, each step should take 24 hours. However, the time frame at each step may vary with Player age, history, etc., and management must be individualized. Club Medical Personnel should monitor progression through the exertional stages as well as continue to consider concurrent morbidities (e.g., migraine, neck, mood, sleep, etc.).
Once a Player diagnosed with concussion is determined by the Club Physician to be free of concussion-related symptoms at rest and upon exertion, the Player shall be referred to the Club's Consulting Neuropsychologist (or, if on the road, a Consulting Neuropsychologist from another team) for a post-concussion evaluation. This evaluation typically occurs prior to the Player engaging in on-ice activity involving controlled body contact, but must occur prior to returning to live game play. At a minimum, the Club's Consulting Neuropsychologist's post-injury evaluation shall consist of a clinical interview, and administration of ImPACT and the NHL Paper and Pencil neuropsychological test battery.
In order to facilitate this evaluation, Club Consulting Neuropsychologists should be advised as soon as a Player is diagnosed with a concussion. Club Consulting Neuropsychologists should be provided with baseline and post-injury SCAT5 data and narratives/reports of the acute medical evaluation, as well as subsequent symptom tracking for review as part of the post-injury assessment.
A Club Physician may request a neuropsychological evaluation prior to full symptom resolution when clinical reasons exist for doing so (e.g., prolonged recovery, complex clinical presentation).
Once complete, the Club Consulting Neuropsychologist shall convey the results of the evaluation to the Club Physician or Club Athletic Trainer (preferably both).
Although neuropsychological test data are very useful in assessing the neurocognitive sequelae of concussion, they should not be used in isolation to make the diagnosis of concussion or as the sole determinant for return-to-play.