St. John Fisher College Intercollegiate Athletics Concussion ...
St. John Fisher College Intercollegiate Athletics Concussion Management Protocol Definition of Concussion Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. (McCrory et al. 2009) As defined on the ImPACT website, a concussion is disturbance in brain function that occurs following either a blow to the head or as a result of the violent shaking of the head.
Signs and Symptoms What are the Signs and Symptoms of Concussion? Most people with a concussion recover quickly and fully. But for some people, symptoms can last for days, weeks, or longer. In general, recovery may be slower among older adults, young children, and teens. Those who have had a concussion in the past are also at risk of having another one and may find that it takes longer to recover if they have another concussion. Symptoms of concussion usually fall into four categories: Thinking/ Physical Emotional/ Remembering Mood Difficulty thinking Headache Irritability clearly Fuzzy or blurry vision Feeling slowed down Nausea or vomiting Sadness (early on)
Difficulty concentrating
Dizziness Sensitivity to noise or More emotional light
Sleep Sleeping more than usual Sleep less than usual
Trouble falling asleep
Balance problems Feeling tired, having no energy
Difficulty Nervousness or remembering new anxiety information http://www.cdc.gov/concussion/signs_symptoms.html
Revised 8/2017
Page 1
Baseline ImPACT Testing All first time student athletes participating on the following teams are required to complete an online computerized baseline ImPACT test before being allowed to tryout/practice: Football, Men’s & Women’s Soccer, Field Hockey, Men’s and Women’s Volleyball, Men’s & Women’s Lacrosse, Baseball, Softball, Pole Vault and High Jumpers, and Men’s & Women’s Basketball. In addition all Juniors who will be beginning their 3rd season of competition and those athletes that sustained a concussion the previous academic year will be required to take a new baseline test.
SWAY Balance and Reaction Time Testing All athletes will also have their balance and reaction time tested using the SWAY System. This is a mobile system that will allow the medical staff another tool to test potentially concussed athletes at any time. It can be used on the sideline, home or on the road to assist in making return to play decisions. If Sway is not available a BESS test can be used to evaluated the athlete’s balance at time of injury.
Time of Injury An athlete that appears to have a concussion or reports to an athletic trainer with signs or symptoms including: headache, pressure in the head, dizziness, nausea, balance issues, feeling “foggy” or “slowed down”, visual or hearing problems, irritability or amnesia, should be considered to have a concussion and be monitored closely. An athlete that is unconscious is to be treated with a suspect head and C-spine injury. They should be transported for further evaluation.
An Athletic Trainer (AT), Team Physician or their designee will evaluate the athlete as outlined below.
1. Perform sideline evaluation if athlete presents during practice/game. The student athlete will be monitored for signs and symptoms of a concussion both at rest and with activity on the sideline. If a concussion is not suspected a return to play may be considered.
2. The student athlete that is symptomatic or fails sideline examination, WILL NOT return to participation for the remainder of the day.
3. Monitor the symptomatic athlete and reassess them at periodic intervals, observing for worsening symptoms. Procedures: •
ATC will complete the Concussion Evaluation and the athlete will be evaluated to get their Initial Concussion Symptom Score.
Revised 8/2017
Page 2
•
The athlete and preferably a roommate will be provided a Head Injury Information Sheet with instructions.
•
The SWAY Test can be given if ATC determines the athlete can tolerate the test.
•
The athlete should be instructed to report for follow up on a daily basis until told otherwise.
•
ATC will document the injury in ATS software
•
The Faculty Athletic Representative (FAR) will be e-mailed the athlete’s name so that their professors can be alerted to their injury.
Post-Concussion Follow-Up (24-48 hours post injury) Preferably the day after the athlete reports with concussion symptoms, the athlete will return for a follow up evaluation to include the following: Procedures: •
ATC will complete a Post Concussion Symptom Scale Form on ATS
•
Neuropsychological Assessment: ImPACT Test 24-72 hours after injury, depending on the severity of symptoms the athlete reports this could be delayed.
•
SWAY Test can be given daily if ATC determines the athlete can tolerate the test.
•
ATC will document all follow up information in the ATS.
Note: The Post Concussion Symptom Scale will be completed by the athlete daily (if the studentathlete is compliant) until the student athlete Self Reports Asymptomatic (SRA), at which time they will begin a step by step progression back to physical activity. Athletes that report with a symptoms score of 15 or below will be allowed to bike on a daily basis at low intensity for 10 minutes as long as their symptoms don’t intensity. Any athlete that was evaluated at an Emergency Room or Urgent Care will be need to be evaluated by the Team Physician or his/her designee. An athlete with severe or worsening symptoms or an athlete with symptoms of concern to the treating AT will be evaluated by the Team Physician or his/her designee in the office or Athletic Training Room.
Revised 8/2017
Page 3
When the student-athlete SRA, they will begin the return to play progression, which will be determined by the AT or physician overseeing the injured athlete.
Day 1 Self-Report Asymptomatic (SRA) 1. Post Concussion Symptom Scale on ATS 2. Neuropsychological Assessment: ImPACT Test •
If a previous test was not back to baseline, a follow up test may be provided every third day so as not to have more than 2 tests in any given week or at the discretion of the Athletic Trainer providing care for the athlete.
3. Cardiovascular exercise in controlled setting •
Exercise bike for 15-20 minutes with increased intensity if was previously biking
•
Monitor symptomology If student-athlete reports symptoms during or after exercise, return the studentathlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
4. Document status in ATS
Day2 Self-Report Asymptomatic (SRA) Athletes that have not returned to their baseline level on ImPACT testing will NOT progress to Step 2 even if they are asymptomatic. Follow up ImPACT testing for athletes that have not returned to their baseline level will be conducted NO MORE than twice weekly and will be determined by the Athletic Trainer caring for the athlete. 1. Neuropsychological Assessment: ImPACT Test-Must be back to baseline to progress to this step! 2. Exertional Functional Activity w/out contact •
Begin on exercise bike for 10 minutes
•
Depending on the sport and point in practice week may progress to Weight workout Running/Sprint Work Team warm up and individual drills (NO Contact)
Revised 8/2017
Page 4
If student-athlete reports symptoms during or after exercise, return the studentathlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA) 3. Document status in ATS
Day 3 Self-Report Asymptomatic (SRA) 1. Evaluate for return to full practice, sport specific. 2. Contact sport athlete will return to practice with No Contact •
Asymptomatic with previous activities
•
If student-athlete reports symptoms during or after exercise/practice, return the student-athlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
3. Document status in ATS Note: Athlete needs to complete a full unrestricted practice, which could be Day 3 SRA above or longer depending on how the concussed athlete progresses, without return of symptoms before being cleared for game competition.
Day 4 Self-Report Asymptomatic (SRA) 1. Contact sport athlete can return to full contact practice if: •
Asymptomatic with previous activities
•
If student-athlete reports symptoms during or after exercise/practice, return the student-athlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
2. Document status in ATS Note: Athlete needs to complete a full unrestricted practice, which could be Day 3 SRA above or longer depending on how the concussed athlete progresses, without return of symptoms before being cleared for game competition.
Day 5 Self-Report Asymptomatic (SRA) Revised 8/2017
Page 5
1. Cleared for game participation 2. Document status in ATS 3. Sway test-A final test as the athlete now has returned to play. 4. Monitor for any setbacks and return to concussion protocol if symptoms return.
Care of the Athlete with Prolonged Concussion Symptoms 1. The athlete with concussion symptoms that persist and is unable to return to sport within 2 weeks will be referred to the team physician or his/her designee for evaluation. 2. Athletes with a previous history of neurological problems, including but not limited to frequent concussions, significant history of previous concussions or prolonged recovery from concussions, must be evaluated and cleared for return to sports by the team physician or his/her designee. 3. The protocol for returning the athlete with prolonged and persistent symptoms to contact activity may be modified once they become asymptomatic. To ensure that the athlete tolerates intense physical activity without a return of concussion related symptoms, they will be required to complete a predetermined number of practices as recommended by the team physician. •
i.e. The football athlete with symptoms lasting longer than 2 weeks may need to complete up to 2 weeks of practices before being cleared for game competition as opposed to the progression outlined above.
Multiple Concussions in the Same Season 1. An athlete that sustains a second concussion in the same season will be referred to the team physician or his/her designee for evaluation. 2. The same progression of activities will be followed as outlined above, but return to play decisions will be at the discretion of the team physician.
Revised 8/2017
Page 6
Return to Learn •
Just like return to activity guidelines, there needs to be return to learn guidelines which will follow a similar step by step increase of cognitive activities for the athlete that sustains a concussion.
•
The majority of student athletes will not need a detailed return-to-learn program because full recovery will occur within 1-2 weeks.
•
For those athletes that have ongoing symptoms lasting longer than three weeks, the management becomes more difficult. These cases will be referred to the Disability Services Office for further academic assistance.
PROCEDURES 1. Cognitive rest will be determined on a case by case process after evaluating the injured athlete and determining their level of symptoms. This can include: No class on same day as concussion Recommendation to not go to class the day or two following concussion as determined by symptoms No studying or a modification of studying, i.e. taking breaks Try to attend class, but if symptoms increase they would need to leave class Attend class as long as symptoms don’t worsen 2. The evaluating Athletic Trainer (AT) will notify the Faculty Athletic Representative (FAR) at the time of injury by e-mail. The FAR will contact the athlete’s professors by e-mail with information stating that a student-athlete in their class has sustained a concussion. This communication will contain information on the signs and symptoms of a concussion, that the athlete may miss class, and that they may need some minor accommodations as they recover from their injury. 3. The athlete will be instructed to reach out to their professors as well to notify them of their injury as there is likely to be some delay in the e-mail process where their symptoms could prevent them from attending class. Current recommendations state there should be no classroom activity on the day of the concussion. It is possible after an afternoon/evening practice/game a concussed athlete may have an increase in their symptoms. This could result in poor sleep and not feeling well enough to attend classes the day following injury as well.
Revised 8/2017
Page 7
4. During the first week or two following an athlete’s concussion, as stated above we will monitor the athlete’s symptoms and assist them in making decisions on how to handle their academics. There may need to be some minor academic adjustments with the athlete as they recover. 5. The AT will provide a weekly update to the FAR regarding where the athlete is in their recovery. 6. An athlete whose symptoms last longer than 2 weeks will be evaluated by a concussion specialist as per the protocol and academic accommodation may be required. This athlete will be referred to the Disability Services Office in Kearney 300 for assistance and getting the proper academic help. 7. Athletes identified as having post-concussion syndrome (symptoms lasting longer than 3-4 weeks) and prolonged cognitive difficulties will require further academic modification. This plan will be initiated by the Disability Services Office after the athlete provides them with the appropriate documentation from their treating physician. 8. Once an athlete is symptom free and is returning to athletic participation, a follow up e-mail will be sent to the FAR who will in turn contact that student-athlete’s professors alerting them to this fact. They should also be progressing back to normal learning function as well, although it’s possible to have setbacks.
Revised 8/2017
Page 8
Signs and Symptoms What are the Signs and Symptoms of Concussion? Most people with a concussion recover quickly and fully. But for some people, symptoms can last for days, weeks, or longer. In general, recovery may be slower among older adults, young children, and teens. Those who have had a concussion in the past are also at risk of having another one and may find that it takes longer to recover if they have another concussion. Symptoms of concussion usually fall into four categories: Thinking/ Physical Emotional/ Remembering Mood Difficulty thinking Headache Irritability clearly Fuzzy or blurry vision Feeling slowed down Nausea or vomiting Sadness (early on)
Difficulty concentrating
Dizziness Sensitivity to noise or More emotional light
Sleep Sleeping more than usual Sleep less than usual
Trouble falling asleep
Balance problems Feeling tired, having no energy
Difficulty Nervousness or remembering new anxiety information http://www.cdc.gov/concussion/signs_symptoms.html
Revised 8/2017
Page 1
Baseline ImPACT Testing All first time student athletes participating on the following teams are required to complete an online computerized baseline ImPACT test before being allowed to tryout/practice: Football, Men’s & Women’s Soccer, Field Hockey, Men’s and Women’s Volleyball, Men’s & Women’s Lacrosse, Baseball, Softball, Pole Vault and High Jumpers, and Men’s & Women’s Basketball. In addition all Juniors who will be beginning their 3rd season of competition and those athletes that sustained a concussion the previous academic year will be required to take a new baseline test.
SWAY Balance and Reaction Time Testing All athletes will also have their balance and reaction time tested using the SWAY System. This is a mobile system that will allow the medical staff another tool to test potentially concussed athletes at any time. It can be used on the sideline, home or on the road to assist in making return to play decisions. If Sway is not available a BESS test can be used to evaluated the athlete’s balance at time of injury.
Time of Injury An athlete that appears to have a concussion or reports to an athletic trainer with signs or symptoms including: headache, pressure in the head, dizziness, nausea, balance issues, feeling “foggy” or “slowed down”, visual or hearing problems, irritability or amnesia, should be considered to have a concussion and be monitored closely. An athlete that is unconscious is to be treated with a suspect head and C-spine injury. They should be transported for further evaluation.
An Athletic Trainer (AT), Team Physician or their designee will evaluate the athlete as outlined below.
1. Perform sideline evaluation if athlete presents during practice/game. The student athlete will be monitored for signs and symptoms of a concussion both at rest and with activity on the sideline. If a concussion is not suspected a return to play may be considered.
2. The student athlete that is symptomatic or fails sideline examination, WILL NOT return to participation for the remainder of the day.
3. Monitor the symptomatic athlete and reassess them at periodic intervals, observing for worsening symptoms. Procedures: •
ATC will complete the Concussion Evaluation and the athlete will be evaluated to get their Initial Concussion Symptom Score.
Revised 8/2017
Page 2
•
The athlete and preferably a roommate will be provided a Head Injury Information Sheet with instructions.
•
The SWAY Test can be given if ATC determines the athlete can tolerate the test.
•
The athlete should be instructed to report for follow up on a daily basis until told otherwise.
•
ATC will document the injury in ATS software
•
The Faculty Athletic Representative (FAR) will be e-mailed the athlete’s name so that their professors can be alerted to their injury.
Post-Concussion Follow-Up (24-48 hours post injury) Preferably the day after the athlete reports with concussion symptoms, the athlete will return for a follow up evaluation to include the following: Procedures: •
ATC will complete a Post Concussion Symptom Scale Form on ATS
•
Neuropsychological Assessment: ImPACT Test 24-72 hours after injury, depending on the severity of symptoms the athlete reports this could be delayed.
•
SWAY Test can be given daily if ATC determines the athlete can tolerate the test.
•
ATC will document all follow up information in the ATS.
Note: The Post Concussion Symptom Scale will be completed by the athlete daily (if the studentathlete is compliant) until the student athlete Self Reports Asymptomatic (SRA), at which time they will begin a step by step progression back to physical activity. Athletes that report with a symptoms score of 15 or below will be allowed to bike on a daily basis at low intensity for 10 minutes as long as their symptoms don’t intensity. Any athlete that was evaluated at an Emergency Room or Urgent Care will be need to be evaluated by the Team Physician or his/her designee. An athlete with severe or worsening symptoms or an athlete with symptoms of concern to the treating AT will be evaluated by the Team Physician or his/her designee in the office or Athletic Training Room.
Revised 8/2017
Page 3
When the student-athlete SRA, they will begin the return to play progression, which will be determined by the AT or physician overseeing the injured athlete.
Day 1 Self-Report Asymptomatic (SRA) 1. Post Concussion Symptom Scale on ATS 2. Neuropsychological Assessment: ImPACT Test •
If a previous test was not back to baseline, a follow up test may be provided every third day so as not to have more than 2 tests in any given week or at the discretion of the Athletic Trainer providing care for the athlete.
3. Cardiovascular exercise in controlled setting •
Exercise bike for 15-20 minutes with increased intensity if was previously biking
•
Monitor symptomology If student-athlete reports symptoms during or after exercise, return the studentathlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
4. Document status in ATS
Day2 Self-Report Asymptomatic (SRA) Athletes that have not returned to their baseline level on ImPACT testing will NOT progress to Step 2 even if they are asymptomatic. Follow up ImPACT testing for athletes that have not returned to their baseline level will be conducted NO MORE than twice weekly and will be determined by the Athletic Trainer caring for the athlete. 1. Neuropsychological Assessment: ImPACT Test-Must be back to baseline to progress to this step! 2. Exertional Functional Activity w/out contact •
Begin on exercise bike for 10 minutes
•
Depending on the sport and point in practice week may progress to Weight workout Running/Sprint Work Team warm up and individual drills (NO Contact)
Revised 8/2017
Page 4
If student-athlete reports symptoms during or after exercise, return the studentathlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA) 3. Document status in ATS
Day 3 Self-Report Asymptomatic (SRA) 1. Evaluate for return to full practice, sport specific. 2. Contact sport athlete will return to practice with No Contact •
Asymptomatic with previous activities
•
If student-athlete reports symptoms during or after exercise/practice, return the student-athlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
3. Document status in ATS Note: Athlete needs to complete a full unrestricted practice, which could be Day 3 SRA above or longer depending on how the concussed athlete progresses, without return of symptoms before being cleared for game competition.
Day 4 Self-Report Asymptomatic (SRA) 1. Contact sport athlete can return to full contact practice if: •
Asymptomatic with previous activities
•
If student-athlete reports symptoms during or after exercise/practice, return the student-athlete to the concussed state/procedures until they Self-Report Asymptomatic (SRA)
2. Document status in ATS Note: Athlete needs to complete a full unrestricted practice, which could be Day 3 SRA above or longer depending on how the concussed athlete progresses, without return of symptoms before being cleared for game competition.
Day 5 Self-Report Asymptomatic (SRA) Revised 8/2017
Page 5
1. Cleared for game participation 2. Document status in ATS 3. Sway test-A final test as the athlete now has returned to play. 4. Monitor for any setbacks and return to concussion protocol if symptoms return.
Care of the Athlete with Prolonged Concussion Symptoms 1. The athlete with concussion symptoms that persist and is unable to return to sport within 2 weeks will be referred to the team physician or his/her designee for evaluation. 2. Athletes with a previous history of neurological problems, including but not limited to frequent concussions, significant history of previous concussions or prolonged recovery from concussions, must be evaluated and cleared for return to sports by the team physician or his/her designee. 3. The protocol for returning the athlete with prolonged and persistent symptoms to contact activity may be modified once they become asymptomatic. To ensure that the athlete tolerates intense physical activity without a return of concussion related symptoms, they will be required to complete a predetermined number of practices as recommended by the team physician. •
i.e. The football athlete with symptoms lasting longer than 2 weeks may need to complete up to 2 weeks of practices before being cleared for game competition as opposed to the progression outlined above.
Multiple Concussions in the Same Season 1. An athlete that sustains a second concussion in the same season will be referred to the team physician or his/her designee for evaluation. 2. The same progression of activities will be followed as outlined above, but return to play decisions will be at the discretion of the team physician.
Revised 8/2017
Page 6
Return to Learn •
Just like return to activity guidelines, there needs to be return to learn guidelines which will follow a similar step by step increase of cognitive activities for the athlete that sustains a concussion.
•
The majority of student athletes will not need a detailed return-to-learn program because full recovery will occur within 1-2 weeks.
•
For those athletes that have ongoing symptoms lasting longer than three weeks, the management becomes more difficult. These cases will be referred to the Disability Services Office for further academic assistance.
PROCEDURES 1. Cognitive rest will be determined on a case by case process after evaluating the injured athlete and determining their level of symptoms. This can include: No class on same day as concussion Recommendation to not go to class the day or two following concussion as determined by symptoms No studying or a modification of studying, i.e. taking breaks Try to attend class, but if symptoms increase they would need to leave class Attend class as long as symptoms don’t worsen 2. The evaluating Athletic Trainer (AT) will notify the Faculty Athletic Representative (FAR) at the time of injury by e-mail. The FAR will contact the athlete’s professors by e-mail with information stating that a student-athlete in their class has sustained a concussion. This communication will contain information on the signs and symptoms of a concussion, that the athlete may miss class, and that they may need some minor accommodations as they recover from their injury. 3. The athlete will be instructed to reach out to their professors as well to notify them of their injury as there is likely to be some delay in the e-mail process where their symptoms could prevent them from attending class. Current recommendations state there should be no classroom activity on the day of the concussion. It is possible after an afternoon/evening practice/game a concussed athlete may have an increase in their symptoms. This could result in poor sleep and not feeling well enough to attend classes the day following injury as well.
Revised 8/2017
Page 7
4. During the first week or two following an athlete’s concussion, as stated above we will monitor the athlete’s symptoms and assist them in making decisions on how to handle their academics. There may need to be some minor academic adjustments with the athlete as they recover. 5. The AT will provide a weekly update to the FAR regarding where the athlete is in their recovery. 6. An athlete whose symptoms last longer than 2 weeks will be evaluated by a concussion specialist as per the protocol and academic accommodation may be required. This athlete will be referred to the Disability Services Office in Kearney 300 for assistance and getting the proper academic help. 7. Athletes identified as having post-concussion syndrome (symptoms lasting longer than 3-4 weeks) and prolonged cognitive difficulties will require further academic modification. This plan will be initiated by the Disability Services Office after the athlete provides them with the appropriate documentation from their treating physician. 8. Once an athlete is symptom free and is returning to athletic participation, a follow up e-mail will be sent to the FAR who will in turn contact that student-athlete’s professors alerting them to this fact. They should also be progressing back to normal learning function as well, although it’s possible to have setbacks.
Revised 8/2017
Page 8
