Athletics

Medical management of sports-related concussion is evolving. In recent years, there has been a significant amount of research into sports-related concussion in high school athletes. HYDE School has established this protocol to provide education about concussion for athletic department staff and other school personnel. This protocol outlines procedures for staff to follow in managing head injuries, and outlines school policy as it pertains to return to play issues after concussion.

HYDE School seeks to provide a safe return to activity for all athletes after injury, particularly after a concussion. In order to effectively and consistently manage these injuries, procedures have been developed to aid in insuring that concussed athletes are identified, treated and referred appropriately, receive appropriate follow-up medical care during the school day, including academic assistance, and are fully recovered prior to returning to activity.

In addition to recent research, two (2) primary documents were consulted in developing this protocol. The “Consensus Statement on Concussion in Sport”, Zurich 2009″ [1], and the “National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion” [2] (referred to in this document as the NATA Statement).

In order to continue serving our student’s safety, HYDE School has also partnered with the Maine Concussion Management Initiative.  MCMI was founded in 2009, through a generous grant from the Goldfarb Center for Public Affairs and Civic Engagement at Colby College. The goal of their program is to enhance the health and safety of Maine high school athletes by educating medical practitioners and school administrators about the dangers of traumatic brain injury and the importance of consistent concussion management. They are a group of physicians, parents, athletic trainers, neuropsychologists, teachers, and other professionals dedicated to minimizing the effects of concussion on Maine youth.

This protocol will be reviewed on a yearly basis, by the HYDE medical staff.

Any changes or modifications will be reviewed and given to athletic department staff and appropriate school personnel in writing.

All athletic department staff will attend a yearly in-service meeting in which procedures for managing sports-related concussion are discussed.

Contents:

1. 1. Recognition of concussion
   2. ImPACT neuropsychological testing requirements
   3. Management and referral guidelines for all staff
   4. Procedures for the Certified Athletic Trainer (ATC)
   5. Guidelines and procedures for coaches
   6. Follow-up care during the school day
   7. Return to play procedures

I. Recognition of concussion

A. Common signs and symptoms of sports-related concussion

1. Signs (observed by others):
   • Athlete appears dazed or stunned
   • Confusion (about assignment, plays, etc.)
   • Forgets plays
   • Unsure about game, score, opponent
   • Moves clumsily (altered coordination)
   • Balance problems
   • Personality change
   • Responds slowly to questions
   • Forgets events prior to hit
   • Forgets events after the hit
   • Loss of consciousness (any duration)
2. Symptoms (reported by athlete):
   • Headache
   • Fatigue
   • Nausea or vomiting
   • Double vision, blurry vision
   • Sensitive to light or noise
   • Feels sluggish
   • Feels “foggy”
   • Problems concentrating
   • Problems remembering
3. These signs and symptoms are indicative of probable concussion. Other causes for symptoms should also be considered.

B. Cognitive impairment (altered or diminished cognitive function)

1. General cognitive status can be determined by simple sideline cognitive testing.

1. AT may utilize SCAT2(Sports Concussion Assessment Tool)[3], SAC, sideline ImPACT, or other standard tool for sideline cognitive testing.

 II. ImPACT neuropsychological testing requirements

1. 1. 1. ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is a research-based software tool utilized to evaluate recovery after concussion. It was developed at the University of Pittsburgh Medical Center (UPMC). ImPACT evaluates multiple aspects of neurocognitive function, including memory, attention, brain processing speed, reaction time, and post-concussion symptoms.
         1. Neuropsychological testing is utilized to help determine recovery after concussion.
      2. All athletes at HYDE School are required to take a baseline ImPACT test prior to participation in sports (usually freshman year).
         1. All athletes/coaches will view a video presentation entitled: “Heads Up: Concussion in High School Sports”, prior to taking the baseline test.
      3. All athletes at HYDE School are required to take a baselines BESS test prior to participation in sports.
      4. Athletes in collision and contact sports (as defined by the American Academy of Pediatrics classifications) are required to take a “new” baseline test prior to participation their junior year.

 III. Management and Referral Guidelines for All Staff

1. Suggested Guidelines for Management of Sports-Related Concussion[4]

1. Athletes with LOC will be evaluated for spinal injury and will be protected and transported as clinical indicators warrant.

2. Any athlete who has symptoms of a concussion, and who is not stable (i.e., condition is changing or deteriorating), is to be transported immediately to the nearest emergency department via emergency vehicle.

3. An athlete who is symptomatic but stable, may be transported by his or her parents/faculty member. The parents/faculty should be advised to contact the athlete’s primary care physician, or seek care at the nearest emergency department, on the day of the injury.

a. HYDE personnel will ALWAYS give parents the option of emergency transportation, even if the above criteria are not met.

IV. Procedures for the Certified Athletic Trainer (ATC)

1. 1. 1. The ATC will assess the injury, or provide guidance to the coach if unable to personally attend to the athlete.
         1. Immediate referral to the athlete’s primary care physician or to the hospital will be made when medically appropriate (see section III)
         2. The ATC will perform serial assessments following recommendations in the NATA Statement, and utilize the SCAT2 (Sport Concussion Assessment Tool 2), as recommended by the Zurich Statement, or sideline ImPACT, if available.
            1. The Athletic Trainer will notify the athlete’s parents and explain assessments, medical care, and all precautions done on behalf of the athlete.
      2. The ATC will notify the duty nurse of the injury immediately after the injury, so that the school RN can initiate appropriate follow-up in school immediately upon the athlete’s return to school.
         1. The ATC will continue to provide coordinated care with the school RN, for the duration of the injury.
         2. If LOC was reported at time of injury or if medically appropriate, ATC will coordinate referral for additional medical care.  Athletes will be seen by our physician in charge of concussion care;  Dr. James L. Glazer, MD, FACSM (MCMI affiliate)
      3. The AT is responsible for administering post-concussion ImPACT testing.
         1. The initial post-concussion testing will be administered as soon as is clinically indicated.
            1. Repeat post-concussion tests will be given at appropriate intervals, dependent upon clinical presentation.
         2. The ATC will review post-concussion test data with the athlete, Dr. Glazer, the Health center staff and the athlete’s parent.
            1. ImPACT data will be forwarded to the school neuropsychological consultant
         3. The ATC will forward testing results to the athlete’s treating physician, with parental permission and a signed release of information form.
         4. The ATC will monitor the athlete, and keep the School Nurse informed of the individual’s symptoms and neurocognitive status, for the purposes of developing or modifying an appropriate health care plan for the student-athlete.
         5. The ATC is responsible for monitoring recovery & coordinating the appropriate return to play activity progression.
         6. The ATC will maintain appropriate documentation regarding assessment and management of the injury.

 V. Guidelines and procedures for coaches: RECOGNIZE, REMOVE, REFER

1. Recognize concussion
   1. All coaches should become familiar with the signs and symptoms of concussion that are described in section I.
   2. Very basic cognitive testing should be performed to determine cognitive deficits.
2.  Remove from activity
   1. If a coach suspects the athlete has sustained a concussion, the athlete should be removed from activity until evaluated medically.
      1. Any athlete who exhibits signs or symptoms of a concussion should be removed immediately, assessed, and should not be allowed to return to activity that day.
3. Refer the athlete for medical evaluation  
   1. Coaches should report all head injuries to the HYDE Certified Athletic Trainer (ATC), as soon as possible, for medical assessment and management, and for coordination of home instructions and follow-up care.
      1. The ATC can be reached at: 860-986-3199.
      2. The ATC will be responsible for contacting the athlete’s parents and providing follow-up instructions.
   2. Coaches should seek assistance from the host site ATC if at an away contest and upon returning to campus notify Hyde’s ATC.
   3. In the event that an athlete’s parents cannot be reached, and the athlete is able to be sent home (rather than directly to MD):
      1. The Coach or ATC should insure that the athlete will be with a responsible individual, who is capable of monitoring the athlete and understanding the home care instructions, before allowing the athlete to go home.
      2. The Coach or ATC should continue efforts to reach the parent.
      3. If there is any question about the status of the athlete, or if the athlete is not able to be monitored appropriately, the athlete should be referred to the emergency department for evaluation. A coach or AT should accompany the athlete and remain with the athlete until the parents arrive.
      4. Athletes with suspected head injuries should not be permitted to drive home.

VI. FOLLOW-UP CARE OF THE ATHLETE DURING THE SCHOOL DAY

1. 1. 1.  Responsibilities of the school nurse after notification of student’s concussion
         1. The athlete will be instructed to report to the school nurse upon his or her return to school. At that point, the school nurse will:
            1. Act as a liaison between ATC, parents, and medical physicians.
            2. Coordinate with ATC, faculty, physicians and family to provide an individualized health care plan based on both the athlete’s current condition, and initial injury information.
         2. Notify the student’s faculty of the injury immediately to make adjustments and accommodations in terms of academics.
         3. If the school RN receives notification of a student-athlete who has sustained a concussion from someone other than the ATC (athlete’s parent, athlete, physician note), the ATC should be notified as soon as possible, so that an appointment for ImPACT testing can be made.
         4. Monitor the athlete on a regular basis during the school day.

 VII. RETURN TO PLAY (RTP) PROCEDURES AFTER CONCUSSION

1. Returning to participate on the same day of injury
   1. As previously discussed in this document, an athlete who exhibits signs or symptoms of concussion, or has abnormal cognitive testing, should not be permitted to return to play on the day of the injury. Any athlete who denies symptoms but has abnormal sideline cognitive testing should be held out of activity.
   2. “When in doubt, hold them out.”
2. Return to play after concussion
   1. The athlete must meet all of the following criteriain order to progress to activity:
      1. Have written clearance from qualified medical personnel , including Athletic Trainer, school nurse and specialist/primary care physician (athlete must be cleared for progression to activity by a physician other than an Emergency Room physician).  Clearance will occur once the athlete’s symptoms, signs, physical exam, and neurocognitive testing is some cases indicate that they are safe to begin the progression.
   2. Once the above criteria are met, the athlete will be progressed back to full activity following a stepwise process, (as recommended by both the Zurich and NATA Statements), under the supervision of the ATC.
   3. Progression is individualized, and will be determined on a case by case basis. Factors that may affect the rate of progression include: previous history of concussion, duration and type of symptoms, age of the athlete, and sport/activity in which the athlete participates. An athlete with a prior history of concussion, one who has had an extended duration of symptoms, or one who is participating in a collision or contact sport should be progressed more slowly.
   4. Stepwise progression as described in the Zurich Statement:
      1. No activity – do not progress to step 2 until asymptomatic
      2. Light aerobic exercise – walking, stationary bike
      3. Sport-specific training (e.g., skating in hockey, running in soccer)
      4. Non-contact training drills
      5. Full-contact training after medical clearance
      6. Game playNote: If the athlete experiences post-concussion symptoms during any phase, the athlete should drop back to the previous asymptomatic level and resume the progression after 24 hours.
   5. ImPAct testing typically occurs just prior to full-contact training in the progression.  Though it may be medically indicated earlier in the course of recovery.
   6. Athletes daily activities will be guided and monitored by ATC in coordination with coaches and Health Center.
   7. The athlete should see the ATC daily for re-assessment and instructions until he or she, has progressed to unrestricted activity, and been given a written report to that effect, from the ATC.
   8. Clearance for competition typically requires that the athlete complete the full return to play progression without symptoms and demonstrate through ImPACT testing that no post-concussive neurological deficits exist. Responsibility for clearance ultimately rests with school medical personnel, including the athletic training staff, nursing staff, and team physician.