Dr. Joshua Rotenberg Pediatric Neurology, Brain Injury myspecialist.clinc

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1 Dr. Joshua Rotenberg Pediatric Neurology, Brain Injury myspecialist.clinc Fort Bend ISD Athletic Department Guidelines for Concussion Management Introduction Approximately 10 percent of all athletes involved in contact sports suffer a Mild Traumatic Brain Injury (MTBI; concussion) each season; some estimates are as high as 19 percent. Because many mild concussions can go undiagnosed and unreported, it is difficult to estimate precisely the rate of concussion in any sport. Symptoms are not always definite, and knowing when it is safe for an athlete to return to play is not always clear. The recognition and management of concussions in athletes can be difficult for a number of reasons: Athletes who have experienced a concussion can display a wide variety of symptoms. Although the classic symptoms (i.e. loss of consciousness, confusion, memory loss and/or balance problems) may be present in some athletes with mild traumatic brain injury, there may not be obvious signs that a concussion has occurred. Post-concussion symptoms can be quite subtle and may go unnoticed by the athlete, team medical staff or coaches. Many coaches and other team personnel may have limited training in recognizing signs of concussion and therefore may not accurately diagnose the injury when it has occurred. Players may be reluctant to report concussive symptoms for fear that they will be removed from the game, and this may jeopardize their status on the team or their athletic careers. Fort Bend ISD is in compliance with HB 2038, 82(R). A student removed from an athletics practice or competition will not be permitted to practice or compete again until the student has been evaluated and cleared to play through a school-issued written statement by the athlete s physician. The athlete s parent/guardian as well as the athlete must return the physician's statement and complete a consent form indicating that they have been informed and agree to the policies established under the return-to-play protocol, understand the risks associated with the student s returning to play and comply with any ongoing requirements outlined by the concussion policy. The athlete and parent/guardian will consent to the physician's disclosure of health information that was related to the concussion treatments and understand the district or school's immunity from liability provisions. Concussion Oversight Team (COT): According to TEC Section : The governing body of each school district and open-enrollment charter school with students enrolled who participate in an interscholastic athletic activity shall appoint or approve a concussion oversight team. The Fort Bend ISD Concussion Oversight Team includes: Jeff Arceneaux ATC, LAT- Athletic Trainer Richard Gregoire, ATC, LAT Athletic Trainer Michelle Hiett ATC, LAT Athletic Trainer Jasmine Johnson, MS ATC, LAT- Athletic Trainer Eric Laughlin LAT, M.Ed. Athletic Trainer Mark Moffett, ATC, LAT Athletic Trainer Thomas Phillips LAT, CMT Athletic Trainer Bryant Spencer ATC, LAT, MBA Athletic Trainer Glen Stroech LAT, M.Ed. Athletic Trainer Kara Sylvester ATC, LAT, M.Ed. Athletic Trainer June Tomlin ATC, LAT, M.Ed. Athletic Trainer Aimee Williams ATC, LAT, M.Ed. Athletic Trainer All Assistant Athletic Trainers for Fort Bend ISD Jeffery Kozak DO Houston Methodist Orthopedics Timothy Sitter MD Houston Methodist Orthopedics David Braunreiter MD Team Physician-Concussion Specialist Kenneth Podell MD MOST Concussion Center Bill Wissen, MA, ATC, LAT- Athletic Trainer Mike Vara, ATC, LAT- Athletic Trainer Jeffery Liang, MD, Richmond Bone and Joint Clinic Rehal Bhojani MD Memorial Hermann Hospital, Sugar Land

2 Concussion or Mild Traumatic Brain Injury (MTBI) - A concussion or MTBI is the common result of a blow to the head or body, which causes the brain to move rapidly within the skull. This injury causes brain function to change which results in an altered mental state (either temporary or prolonged). Physiologic and/or anatomic disruptions of connections between some nerve cells in the brain occur. Concussions can have serious and long-term health effects, even from a mild bump on the head. Symptoms include, but are not limited to, headache, amnesia, nausea, dizziness, confusion, blurred vision, ringing in the ears, loss of balance, moodiness, poor concentration or mentally slow, lethargy, photosensitivity, sensitivity to noise and a change in sleeping patterns. Symptoms can also include a loss of consciousness but many do not. These symptoms may be temporary or long lasting. Second Impact Syndrome Second Impact Syndrome (SIS) refers to catastrophic events that may occur when a second concussion occurs while the athlete is still symptomatic and healing from a previous concussion. The second injury may occur within days or weeks following the first injury. Loss of consciousness is not required. The second impact is more likely to cause brain swelling with other widespread damage to the brain. This can be fatal. Most often SIS occurs when an athlete returns to activity without being symptom-free from the previous concussion. Responsible Individuals: At every activity under the jurisdiction of the UIL in which the activity involved carries a potential risk for concussion in the participants, there should be a designated individual who is responsible for identifying student-athletes with symptoms of concussion injuries. That individual should be a physician or an advanced practice nurse, athletic trainer, neuropsychologist, or physician assistant, as defined in TEC section , with appropriate training in the recognition and management of concussion in athletes. In the event that such an individual is not available, a supervising adult approved by the school district with appropriate training in the recognition of the signs and symptoms of a concussion in athletes could serve in that capacity. When a licensed athletic trainer is available such an individual would be the appropriate designated person to assume this role. The individual responsible for determining the presence of the symptoms of a concussion is also responsible for creating the appropriate documentation related to the injury event. Prevention Strategies Helmets, headgear and mouth guards do not prevent all concussions, but can reduce the amount or severity of MTBI. 1. All headgear must be NOCSAE certified. 2. Fitting and use must comply with manufacturers recommendations and make sure the headgear fits the individual. 3. For all sports that require headgear, a coach/appropriate designate should check headgear before use to make sure air bladders work and appropriately filled. Athletes must help to maintain helmet fit (i.e., check air, looseness, tightness). Padding should be checked to make sure the helmet is in proper working condition. 4. Make sure helmets are secured properly at all times. 5. Mouth guards should fit and be used at all times Recovery and safe return-to-play: It is crucial to allow enough healing and recovery time following a concussion to prevent further damage. Research suggests that the effects of repeated concussion are cumulative over time. Most athletes who experience an initial concussion can recover completely as long as they do not return to contact sports too soon. Following a concussion, there is a period of changed brain function that may last anywhere from 24 hours to 10 days, or more. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases.

3 Evaluation for Concussion/MTBI 1. At time of injury administer one of these assessment tests: a. Sports Concussion Assessment Tool (SCATII) b. Graded Symptom Checklist (GSC) 2. Observe athlete 15 to 20 minutes and re-evaluate. 3. Athlete does not return to a game or practice if he/she has any signs or symptoms of MTBI/concussion. 4. Doctor Referral 5. Home Instructions 6. Return to Play Guidelines for Parents 7. Note - If in doubt, athlete is referred to physician and does not return to play. Concussion Management 1. Recommended school modifications a. Inform Principals, school nurse and counselor about the student that has MTBI b. Notify counselor, principals and school nurse of post concussion symptoms c. Student may need special accommodations such as limited computer work, reading activities, testing, assistance to class, etc. until symptoms subside d. Student may only be able to attend school for half days or may need daily rest period until symptoms subside with physician authorization 2. Student must be asymptomatic before return to play protocol begins. 3. Student will not return to full practice or competition for minimum of seven days. 4. The treating physician must provide a written statement to the parent and athletic department indicating that, in the physician s judgment, is safe for the student to return to play. 5. Student athlete and the parent/guardian have signed the form acknowledging the completion of the return to play guidelines which includes the understanding the risks associated with the student athlete s return to play. Return to Play Guidelines Athlete must show no signs of post-concussion symptoms for 48 hours before return to play protocol begins. 1. Athlete activity progressions a. Light aerobic exercise with no resistance training b. Moderate aerobic activity with resistance training c. Sport specific activity and Non-contact training drills d. Full contact training drills can begin after minimum 7 days e. Return to full participation (pending physician clearance) f. Note Athlete activity progression continues as long as athlete is asymptomatic at current level. If the athlete experiences any post concussion symptoms, stop physical activity until symptom free for hours. Resume with phase or level in which they were previously asymptomatic. 2. Physician clearance before full contact training drills stage 3. Athletic Department documentation on file See Appendix

4 For Middle School Athletes If a student athlete demonstrates signs or symptoms consistent with a concussion, the following plan will be implemented: 1. The student athlete or spirit group member shall be immediately removed from the game or practice (to include any weight training or conditioning sessions). 2. The student athlete will be evaluated by the FBISD Athletic Trainer aligned with Middle School or on-site Licensed Athletic Trainer, if available. (Arrangements will be made for the evaluation by the FBISD Coach) athlete will be notified and provided information about the possible concussion. 3. FBISD Athletic Trainer will arrange, with the parent or another person with legal authority to make medical decisions for the student, appropriate evaluation by a physician. The Athletic Coordinators at the Middle Schools will contact the parent/guardian to arrange for the student to be evaluated by a physician or licensed health care professional. 4. If it is determined that a concussion has occurred, the student athlete shall not be allowed to return to participation that day regardless of how quick the signs or symptoms of the concussion resolve and shall be kept from activity until the following requirements have been met: a. The treating physician has provided the parent/guardian of the student athlete and the athletic trainer or athletic coordinator and designated Administrator, a written statement indicating that, in the physician s professional judgment, it is safe for the student to return to play. b. All steps of the Return to Play Progression Protocol have been met (supervised by the FBISD Athletic Trainer). t Below is the High School to Middle School Vertical Alignment: High School Middle School Austin Garcia / Sartartia Bush Hodges Bend / C rockett Clements Fort Settlement / First Colony Dulles Dulles Elkins Quail Valley Hightower Lake Olympia Kempner Sugar Land Marshall Missouri City Ridge Point Baines Travis Bowie Willowridge McAuliffe

5 Dear Parent or Guardian: Your child sustained a head injury while participating in a school activity. It is important for your child to check in with the licensed athletic trainer before he / she goes to class after their injury. Please be observant for the following signs and symptoms:(if one or more symptoms occur, Please Take to ER) Headache that increases in intensity* Nausea and vomiting* Difference in pupil size from right to left eye, dilated pupils* Mental confusion / behavior changes, dizziness, memory loss, ringing in the ears Changes in gait or balance Blurry or double vision* Slurred speech* Noticeable changes in level of consciousness (Difficulty awakening or loss of consciousness suddenly)* Seizure activity* Decreased or irregular pulse or respirations The best guideline is to note symptoms that worsen and behaviors that seem to represent a change in your child. If you have any question or concern about the symptoms that you are observing, contact your family physician or go to the emergency room. The chart on the right may be helpful in knowing what to do if your child is suspected of having suffered a concussion. It is OK to: Use acetaminophen (Tylenol) for headaches Use ice pack on head & neck as needed for comfort Eat a light diet Go to sleep Rest (no strenuous activity or sports) There is NO need to: Check eyes with a flashlight Wake up every hour Test reflexes Stay in bed Do NOT: Drink Alcohol Drive while symptomatic Exercise or lift weights Take ibuprofen, aspirin, naproxen or other non-steroidal anti-inflammatory medications

6 FORT BEND ISD Parental Notice and Physician Release Form To be completed by District: To be completed by the student s treating physician: Athlete: Sport: The athlete named to the left may have sustained a concussion and has been removed from practice / play as required by state law. The student may not return to practice / play until the student has seen a physician of his / her choice and the physician and the student s parent / guardian indicate in writing that the student can return to play. Once the treating physician releases the student to return to play, the student will be required to complete the Return- To-Play Protocol before full-unrestricted participation is allowed. of injury: Time of Injury: After your evaluation, please check the appropriate blank: Activity Supervisor: Witness (check): Yes No Athlete is cleared to begin the required Return-to-Play Protocol. Once the athlete completes the protocol, the athlete is cleared for full participation. Explanation of injury and location: Athlete is cleared to begin the required Return-to-Play Protocol. Once the athlete completes the protocol, they must return to my office for reevaluation before being cleared for full participation. Athlete is not cleared. Athlete must return to my office on for further evaluation. Physician s Signature

7 To Parent/Guardian: State law requires that a student believed to have sustained a concussion must be immediately removed from practice / competition and cannot participate in the activity until the student s treating physician evaluates the student, the parent / Guardian provides the District with a written statement from the physician that the student can return to play, and the student completes the Return-to-Play Protocol. This same law also requires that before the student can play, the parents must give written consent for their student to return to play. The physician must complete and sign this form or send written instructions and you must return it to school before your child will be able to participate. Your signature authorizes a District licensed athletic trainer or nurse to contact your child s physician to discuss issues related to your child s injury and to disclose information from your child s physician to appropriate school personnel. Parent/Guardian s Name (Sign): Return-to-Play Protocol No exertional physical activity until student athlete is symptom free for 24 hours and received written clearance from a physician to be able to begin the Return-to-Play Protocol. Completed form must be submitted to their campus athletic trainer (High School Athlete) or their coach (Middle School Athlete) of their required documentation following the concussion injury before they can begin any activity after a concussion. Step 1: Light aerobic exercise with no resistance training as outlined in the UIL Implementation Guide Step 2: Moderate aerobic exercise as outlined in the UIL Implementation Guide Step 3: Non-contact training drills with resistance training as outlined in UIL Implementation Guide Step 4: Full Contact practice or training drills as outlined in the UIL Implementation Guide Step 5: Full game play as outlined in the UIL Implementation Guide after the parent has signed / completed the UIL Return-to-Play Form Athlete progression continues as long as athlete is asymptomatic at current activity level. If the athlete experiences any post-concussion symptoms, he / she will wait 24 hours and start the progressions again at the previous activity level. Name FORT BEND ISD Pre-Participation Concussion Information & Acknowledgement During the 82 nd legislative session, a state law was passed providing for the prevention, treatment and oversight of concussions affecting students involved in interscholastic activities. This law requires each school district create one or more Concussion Oversight Teams. The law requires that any student suspected of suffering a concussion be immediately removed from practice/competition until a physician sees student. The law requires that before a student may return to play, the student must complete a five-day Return-to-Play Protocol and parents acknowledge in writing that they have received information regarding concussion prevention, symptoms, treatment and oversight, and that parents separately grant permission in writing for their child to return to full participation. The purpose of this document is to provide you the information required by law relating to concussions. If you have any questions, please contact Fort Bend ISD Athletic Director, Phillip O Neal at

8 A concussion is defined as a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head that can change the way the brain normally works. Concussions can also occur from blow to the body that causes the head to move rapidly back and forth. Even or what seems to be a mild bump on the head can be serious and cause a concussion. The following are signs and symptoms of a concussion: Headache that increases in intensity* Nausea and vomiting* Difference in pupil size from left to right eye, dilated pupils* Mental confusion / behavior changes, dizziness, memory loss, ringing in the ears Changes in gait or balance Blurry or double vision* Slurred Speech* Noticeable changes in level of consciousness (difficulty awakening or loss of consciousness suddenly)* Seizure Activity* Decreased or irregular pulse or respirations* *Seek medical attention at the nearest emergency room The best guideline is to note symptoms that worsen, and behaviors that seem to represent a change in your child. If you have any questions/concerns about the symptoms you are observing, contact your family physician or go to the emergency room. The following chart may be helpful in knowing what to do if you child is suspected of having suffered a concussion. It is OK to: o Use acetaminophen (Tylenol) for headaches o Use ice pack on head & neck as needed for comfort o Eat a light diet o Go to sleep o Rest (no strenuous activity or sports) There is NO need to: o Check eyes with a flashlight o Wake up every hour o Test reflexes o Stay in bed Do NOT: o Drink alcohol o Drive while symptomatic o Exercise of lift weights o Take ibuprofen/aspirin/naproxen/non steroidal antiinflammatory meds The State s protocol for managing concussions includes a multidisciplinary approach involving licensed athletic trainer or school nurse clearance, physician referral and clearance, and successful completion of activity progressions related to your child s sport. Below is an outline of this procedure that is referred to as the Return-to-Play Protocol. Before your son/daughter can return to his/her sport/activity after having sustained a concussion, he/she must: Be evaluated by a physician chosen by you. The physician must complete the District form indicating a normal physical and neurological exam. Without this acknowledgement from your physician, your child will not be permitted to begin the Return-to-Play Protocol. Be monitored daily at school by the licensed athletic trainer. His/her teachers may be notified of the injury and what to expect. Accommodations may be given depending on the recommendations made by your physician. Be asymptomatic at rest and exertion at each step of the progression through the Return-to-Play Protocol. Complete the Return-to-Play Protocol after being cleared by his / her physician. The Protocol is a progressive step-by-step procedure that advances at the rate of one step per day. The Return-to-Play Protocol is: o Step 1: Light aerobic exercise with no resistance training as outlined in the UIL Implementation Guide o Step 2: Moderate aerobic exercise as outlined in the UIL Implementation Guide o Step 3: Non-contact training drills with resistance training as outlined in the UIL Implementation Guide o Step 4: Heavy non-contact physical exercise as outlined in the UIL Implementation Guide o Step 5: Full game play as outlined in the UIL Implementation Guide after the parent has signed / completed the UIL Return-to-Play form o Athlete progression continues as long as athlete is asymptomatic at current activity level. If the athlete experiences any post concussion symptoms, he / she will wait 24 hours and start the progressions gain at the previous activity level. o Return the signed UIL Return-to-Play Form to your child s licensed Athletic Trainer. My child and I have received and read the information provided by the District explaining concussion prevention, symptoms, treatment, oversight, and guideline for safely returning to play after a concussion. Athlete s Name (Print ) Athlete s Signature Parent / Guardian s Name (Print) Parent / Guardian s Signature

9 FORT BEND ISD CONCUSSION CHECKLIST Athlete s Name Grade of Injury Time of Injury Sport / Coach Parent Information / Signature Treating Physician Clearance Physician s Name Seen for release to progression Progression (initial and date) Step 1: 24 hours symptom free Licensed athletic trainer Phase 1 Step 2: Low levels of physical exertion as tolerated (symptoms do not get worse or come back during or after the activity). This includes walking, light jogging, light stationary biking, light weightlifting (lower weight, higher reps, no bench, no squat). Maintain this level of exertion until re-evaluation. Licensed athletic trainer Step 3: Moderate levels of physical exertion as tolerated. This includes moderate jogging/brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (reduced time and/or reduced weight from your typical routine. Licensed athletic trainer UIL Return to Play Form completed before Step 4 Step 4: Heavy non-contact physical exertion as tolerated. This includes sprinting/running, high-intensity stationary biking, regular weightlifting routine, non-contact sport-specific drills. Maintain this level of exertion until re evaluation Licensed athletic trainer Phase 2 Step 5: May begin full contact practice/play on if asymptomatic with heavy exertion Licensed athletic trainer The above athlete has completed the UIL Return to Play Protocol and is symptom free. Supervising licensed Athletic Trainer Signature

WISD Athletic Department Guidelines for Concussion Management

WISD Athletic Department Guidelines for Concussion Management Introduction Approximately 10 percent of all athletes involved in contact sports suffer a Mild Traumatic Brain Injury (concussion) each season;