Administrative Regulations on Concussion
In November of 2011, Governor Tom Corbett and the General Assembly of Pennsylvania passed SB 200, the Safety in Youth Sports Act, establishing standards for management of concussions and traumatic brain injuries (TBI) to student athletes. As of July 1, 2012, it became mandatory for Pennsylvania schools, and all personnel who supervise or medically treat student-athletes, to follow the stated requirements.
Below is an outline of the concussion protocol that the Sports Medicine department of Upper Perkiomen School District will begin using starting the 2017-2018 school year. The information included in this document has been established to ensure the best possible scenario for returning student-athletes in the safest possible manner to both the field and the classroom.
Background
A concussion is a traumatic brain injury (TBI) caused by a direct or indirect blow to the head or body. The Center for Disease Control and Prevention estimates that as many as 3.8 million sports and recreation related concussions occur in the United States each year. By making the Safety in Youth Sports Act (Act of Nov. 9, 2011, P.L. 411, No. 101) into law, there are specific requirements for Pennsylvania schools and the personnel who supervise the student-athletes that represent these schools, as well as the medical personnel that support them when there is an injury. Allowing a student-athlete to return to play or to return to the classroom before recovering from a concussion increases the chance of continuing symptoms or predisposition for a more serious brain injury that can result in severe disability and/or death.
Concussion Policy
- Once each school year, a coach shall complete the concussion management certification training course offered by the Centers for Disease Control and Prevention (CDC), the National Federation of State High School Associations (NFHS), or another provider posted on the website by the Pennsylvania Departments of Education or Health. A coach shall not supervise an athletic activity until he/she completes the training course required under this subsection.
- The school shall hold an informational meeting, prior to the start of each athletic season, for all competitors regarding concussion management and how pre-season baseline assessments can aid in the evaluation, management and recovery process. These meetings may also include parents, guardians, coaches, physicians, neuropsychologists, and athletic trainers.
- Any student desiring to participate in any athletic activity and the student’s parent or guardian must, each school year, sign and return to the school an acknowledgement of their receipt and review of concussion and traumatic brain injury information.
- Authority is granted to game officials, the coach, certified athletic trainer, licensed physician or other individual trained in the recognition of the signs and symptoms of a concussion and designated by the school, to determine that a student-athlete exhibits signs or symptoms of a concussion or TBI.
- Once the student-athlete has exhibited signs or symptoms of a concussion/TBI he or she must be removed by the coach from participation and referred to the Certified Athletic Trainer for further evaluation. If the student-athlete is deemed to exhibit signs and symptoms of a concussion and these are accompanied by a mechanism for the injury, the student-athlete CANNOT return to practice or competition until the student-athlete is evaluated and cleared for return to participation in writing by an appropriate medical professional with training in the evaluation and management of concussion.
- Appropriate medical professional is defined as a licensed physician of medicine or osteopathic medicine (MD or DO) comfortable with current concussion management principles.
- Coaches pressuring athletes to return-to-play quicker will not be tolerated.
- Any coach who violates this policy will incur the following disciplinary actions:
- First offense: The coach will be suspended for the remainder of that season.
- Second offense: The coach will be suspended from coaching any athletic activity for the remainder of that season and for the next season.
- Third offense: The coach will be permanently suspended from coaching any athletic activities.
Procedures
Student-athletes who are exhibiting any of the signs or symptoms of a sports-related concussion or other head injuries during practice or competition shall be immediately removed from play and may not return to play until he/she is evaluated and cleared for return to participation by an appropriate medical professional (MD/DO).
Signs of Concussion
May be observed by Coaches, Certified Athletic Trainers, Team Physician or School Nurse
Including, but not limited to:
- Athlete appears dazed, stunned, disoriented, or demonstrates decreased alertness
- Forgets plays, or demonstrates short term memory difficulty
- Slurring of speech
- Abnormal pupillary response or nystagmus
- Exhibits difficulties with balance or coordination
- Answers questions slowly or inaccurately
- Exhibits seizures or vomiting
- Changes in level of consciousness
- Formerly, concussion models relied upon loss of consciousness (LOC) as a defining symptom of concussion. It is now estimated that <10% of concussions result in the loss of consciousness.
Symptoms of Concussion
As reported by the student-athlete to Coaches, Certified Athletic Trainers, Team Physician, School Nurse or Parent/Guardians.
- Headache
- Nausea
- Balance problems or dizziness
- Double vision or changes in vision
- Sensitivity to light or sound/noise
- Feeling sluggish or foggy
- Difficulty with concentration and short term memory
- Sleep disturbance
- Irritability or changes in personality and behavior
Once a student-athlete has been removed from competition or practices because of signs or symptoms of a concussion, the following Concussion Management Protocol must be followed:
- Emergency medical treatment should be pursued if there is a deterioration of symptoms including seizure, altered level of consciousness, vomiting, altered pupillary findings, or direct neck pain associated with the injury.
- All appropriate school officials should be notified of the event, including the team physician, certified athletic trainer, athletic director, school nurse, school counselor and all of the student’s teachers.
- School officials must make contact with the student-athlete’s parent/guardian and inform him/her of the suspected sports-related concussion or head injury.
- School officials shall provide the student-athlete and their parent/guardian with information on the continuing care of a person with concussion. This material is also available through the Pennsylvania Departments of Health or Education, or the Centers for Disease Control and Prevention (www.cdc.gov).
- The student-athlete must be evaluated by an appropriate medical professional (MD or DO) trained in the evaluation and management of concussions.
- The student-athlete must receive written clearance from an MD or DO that states the student-athlete is asymptomatic at rest and may begin a graduated return to play protocol.
- The student-athlete shall receive final clearance in the form of the PIAA CIPPE form 7 from the treating physician (MD or DO).
Complete physical, cognitive, emotional, and social rest is advised while the student-athlete is experiencing symptoms and signs of a concussion/traumatic brain injury. Minimize mental exertion, limiting overstimulation, limit cell phone and computer usage, testing, video gaming, multi-tasking, etc.
Return-to-Play
After written medical clearance is given by a MD or DO, the student-athlete may begin a graduated individualized return-to-play protocol, supervised by the school district’s certified athletic trainer or team physician. Each concussion is different and therefore the following is not an exact format. The following five-day return to play protocol should be utilized:
- Athlete remains symptom-free, off medication, for a 24 hour period while completing a day of normal cognitive activities (school day, studying for class, and interaction with peers). If no return of symptoms, progress to next step:
- Light aerobic exercise, 15-40 minutes in length, keeping the intensity <70% maximum predicted heart rate. The objective is to increase heart rate. If no return of symptoms, progress to next step:
- Sport specific drills, 15-40 minutes in length. Drills should be individual (i.e. change of direction, change of pace/intensity, cutting, agility) and exclude all head impact activities. The objective is to add movement while continuing to increase heart rate. If no return of symptoms, progress to next step:
- Non-contact training drills, may be done individually or with a team. This may include sport specific skills such as passing, shooting, throwing, etc. Progressive resistance training may begin during this phase. If no return of symptoms, progress to next step:
- Unrestricted participation in practice or normal training activities. The student-athlete may participate in all team drills, including contact, in practice only. The objective is to restore confidence to the student-athlete and assess functionality of the athlete during play. If no return of symptoms, progress to next step:
- Return to play involving normal exertion or game activity
Each step should be progressed through a 24-hour period. At the athletic trainer’s discretion, if symptoms emerge and the progression is stopped, the athlete will return to the previous step that did not cause a re-occurrence of symptoms. If an athlete remains stalled at the same phase for three days without improvement, they will be referred back to the treating physician that granted clearance for the injury.
Utilization of standardized tools such as symptom checklists and Standardized Assessment of Concussion testing, as well as comparison of post-injury performance to baseline cognitive testing scores and balance testing is suggested.
Return-to-Classroom
Temporary learning support accommodations may be needed for student-athletes with sports-related head injuries to return to the classroom. This is the reason for school officials, school counselors and teachers to be part of the plan for the student-athlete.
Rest is the best “medicine” for healing concussions or other head injuries. The concussed brain is affected in many functional aspects as a result of the injury. Memory, attention span, concentration and speed of processing significantly impact learning. While each individual situation and injury is different, exposing the concussed student-athlete to the stimulating school environment may exacerbate symptoms and delay the resolution of symptoms needed for recovery. Because of this, consideration of the cognitive effects in returning to the classroom is an important part of concussion treatment as a whole.
Students returning to school after a concussion/traumatic brain injury may need:
- Additional rest breaks during the school day
- Shortened length of the school day
- Additional time for completion of assignments or exams
- Additional help with routine school work (pre-teaching, outlines, etc.)
- Reduced time spent on the computer, as well as reading and writing
- Additional time in between class periods in an effort to avoid crowded hallways
- No standardized testing (PSSA, SAT, etc.) during the initial recovery window of two to four weeks.
The school (teachers, school counselors, school nurse, etc.) and family should monitor the performance of the student closely for two weeks after the return to school. If the return to the classroom causes concussion symptoms to re-occur or if the student demonstrates uncharacteristic performance (reduced attention span, inability to take tests, acting out in class, etc.), further academic accommodations should be made and the student will be referred by to the diagnosing physician.
Programs, such as BrainSTEPS teams, developed by the Brain Injury Association of Pennsylvania with funding from the Pennsylvania Department of Health and the Department of Education, are designed to support the staff, student, and parents or guardian in the return to school process. More information is available at www.brainsteps.net.
It has been widely established that baseline neurocognitive testing is a valuable tool in assisting trained sports medicine clinicians in making return to play decisions. Starting the fall of 2017-2018, all our sports teams at Upper Perkiomen will be baseline tested prior to each season.
Resources on Interscholastic Sports Related Concussions and Head Injuries
Internet Resources
Centers for Disease Control and Prevention – Concussion Toolkit
http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
http://www.cdc.gov/concussion/headsup/pdf/ACE-a.pdf
http://www.cdc.gov/concussion/headsup/pdf/ACE_care_plan_school_version_a.pdf
http://www.cdc.gov/concussion/headsup/pdf/Concussion_in_Sports_palm_card-a.pdf
National Federation of State High Schools Association – Online “Concussion in Sports” training program
Brain Injury Association of Pennsylvania (BIAPA)
Pennsylvania Interscholastic Athletic Association (PIAA)
Pennsylvania Athletic Trainers Society (PATS)
Pennsylvania Physical Therapy Association (PPTA)
Articles
“Consensus Statement on Concussion in Sport: 3rd International Conference on Concussion in Sport held in Zurich, November 2008”. Clinical Journal of Sorts Medicine, Volume 19, May 2009, pp.185-200.
Halstead ME, Walter, KD and the Council on Sports Medicine and Fitness, Clinical Report: Sport-related Concussion in Children and Adolescents” Pediatrics Volume 126, September 2010, pp. 597-615.
McGrath, N. Supporting the Student/athlete’s return to the classroom after a sport-related concussion, Journal of Athletic Training. 2010;45(5): 492-498.
Kutcher, J. & Eckner, J. (2010). At-risk population in sports-related concussion. Current Sports Medicine Reports, 9(1), 16-20.
Grady, M. (2010). Concussion in the Adolescent athlete. Current Problems in Pediatric And Adolescent Health Care. 40(7), 154-169.