Head Injury Assessment Tool HIA 2 - LNR

1 Player s name: Competition: Date:DDMM/YYYY/Form completed by:Team doctor MDD OtherWas a HIA 1 form completed for this event? Yes No, the player presented with symptoms after the matchThis form should be completed on all players removed permanently from the field following a headinjury and on all players who have had a HIA independent of the result. It should also be completed on any player who develops concussive symptoms after the the player: How do you feel?

2 You should score each symptom, based on how the player feels at the time of questioning:*This score is determined by counting the number of individual symptoms reported. The result shouldbe compared to each individual's baseline score. For athletes without a baseline score, any symptomdeclared in the symptom list which is not usually experienced by the player following a Rugby match ortraining is strongly in favour of concussion.**This score is determined by adding up each number related to a reported symptom and is generallyused to monitor recovery of a Pressure in head 0123456 Neck pain0123456 Nausea or vomiting0123456 Dizziness0123456 Blurred vision0123456 Balance problems0123456 Sensitivity to light0123456 Sensitivity to noise0123456 Feeling slowed down0123456 Feeling like in a fog 0123456 Don t feel right 0123456 Difficulty concentrating0123456 Difficulty remembering0123456 Fatigue or low energy0123456

3 Confusion0123456 Drowsiness0123456 Excessive tiredness0123456 More emotional0123456 Irritability0123456 Sadness0123456 Nervous or anxious0123456 Number of symptoms*: /22 Severity of symptoms**: /132 HIA 2 Team:Time:Head Injury Assessment ToolSTANDARDISED Assessment of CONCUSSION (SAC) AND BALANCE TESTSORIENTATION (1 point for each correct answer)What month is it?01 What is the date today?01 What is the day of the week?01 What year is it?01 What time is it right now? (within 1 hour)01 Orientation score: out of 5 IMMEDIATE MEMORYListTrial 1 Trial 2 Trial 31.

4 Elbow0101012. Apple0101013. Carpet0101014. Saddle0101015. Bubble010101 TOTALI mmediate memory score: out of 15 CONCENTRATION: DIGITS BACKWARDListTrial 1 Alternative digit lists4 9 - 3016 2 95 2 64 1 53 8 1 4013 2 - 7 - 91 7 9 54 9 6 86 2 9 7 - 1011 5 2 8 - 63 8 5 2 76 1 8 4 37 1 8 4 6 - 2015 3 9 1 4 - 88 3 1 9 6 - 47 2 4 8 5 - 6 CONCENTRATION: MONTHS IN REVERSE ORDER (1 point for entire sequence correct)Dec-Nov-Oct-Sep-Aug-Jul-Jun-May- Apr-Mar-Feb-Jan01 Concentration score: out of 5 Alternative word lists (use five words)1.

5 Candle2. Paper3. Sugar4. Sandwich5. Wagon1. Baby2. Monkey3. Perfume4. Sunset5. Iron1. Finger2. Penny3. Blanket4. Lemon5. InsectHIA 2 Head Injury Assessment ToolSTANDARDISED Assessment of CONCUSSION (SAC) AND BALANCE TESTSUPPER LIMB CO-ORDINATIONLeftRightWhich arm was tested?Co-ordination score: out of 1 DELAYED RECALLWordElbow01 Apple01 Carpet01 Saddle01 Bubble01 TOTALSAC SCOREO rientation/5 Immediate memory/15 Concentration/5 Delayed recall/5 TOTALA ssessment of a population of Rugby players suffering from a concussive Injury will usually elicit the following results: Total SAC score 24 or below Concentration score 2 or below (digits backward) Delayed recall 3 or less words /30At the end of HIA 2, the diagnosis of concussion is.

6 Now confirmedProbable, but I prefer to consider the player concussedExcludedBALANCE EXAMINATIONNo. of errorsDouble leg stanceSingle leg stanceTandem stanceTOTAL BALANCE SCOREA ssessment of a population of Rugby players suffering from aconcussive Injury will usually elicit the following results: Tandem test - 3 or more errors Single leg stance - 4 or more errorsHIA 2 Alternative word lists (use five words)1. Candle2. Paper3. Sugar4. Sandwich5. Wagon1. Baby2. Monkey3. Perfume4. Sunset5. Iron1. Finger2.

7 Penny3. Blanket4. Lemon5. InsectHead Injury Assessment ToolIMMEDIATE MEMORY I am going to test your memory. I will read you a listof words and when I am done, repeat back as manywords as you can remember, in any order. Trials 2 and 3: I am going to repeat the same listagain. Repeat back as many words as you canremember in any order, even if you said the wordbefore. Complete all 3 trials regardless of score on trial 1and 2. Read the words at a rate of one per one point for each correct response. Totalscore equals sum across all 3 trials.

8 Do not informthe athlete that delayed recall will be backward: I am going to read you a string of numbers and whenI am done, you repeat them back to me backwards, inreverse order of how I read them to you. For example,if I say 7-1-9, you would say 9-1-7. If correct, go to next string length. If incorrect, readtrial 2. One point possible for each string after incorrect on both trials. The digits shouldbe read at the rate of one per in reverse order: Now tell me the months of the year in reverse with the last month and go backward.

9 So you llsay December, November .. Go ahead. Score one point for entire sequence LIMB CO-ORDINATIONF inger-to-nose (FTN) task: I am going to test your co-ordination now. Please sitcomfortably on the chair with your eyes open andyour arm (either right or left) outstretched (shoulderflexed to 90 degrees and elbow and fingersextended). When I give a start signal, I would like youto perform five successive finger-to-nose repetitionsusing your index finger to touch the tip of the nose asquickly and as accurately as possible.

10 Scoring: Able to complete 5 correct repetitions inless than 4 seconds = 1 pointAthletes fail the test if they do not touch their nose,do not fully extend their elbow or do not perform fiverepetitions. Failure should be scored as TESTThis balance testing is based on a modified versionof the Balance Error Scoring System (BESS). Astopwatch or watch with a second hand is requiredfor this testing. I am now going to test your balance. Please takeyour shoes off, roll up your pant legs above ankle (ifapplicable), and remove any ankle taping (ifapplicable).