Introduction. Second Impact Syndrome

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1 Introduction The Centers for Disease Control (CDC) estimates that there are approximately 300,000 cases of mild traumatic injury (MTBI) or concussions annually in the United States as the result of participation in sports. The Sports Concussion Institute estimates that 10 percent of athletes in contact sports suffer a concussion during a season. A 2006 report estimated that there were 92,000 cases of concussions in American high school sports annually, and that these rates seem to be rising. The term mild traumatic brain injury (MTBI) is used interchangeably with the term concussion. An MTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). MTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or even longer in some cases. Second Impact Syndrome It is well known that athletes will often under report signs and symptoms of a concussion because of the fear of not being able to participate. Because of this, teenage athletes are at risk of suffering repeated concussions and second impact syndrome. These two problems can have long lasting, and even terminal effects on the individual. Second impact syndrome is a very rare condition in which a second concussion occurs before a first concussion has properly healed, causing rapid and severe brain swelling and often catastrophic results. Second impact syndrome can result from even a very mild concussion that occurs days or weeks after the initial concussion. That is why if an athlete has suffered a concussion, it is best if they do not return to their sport until the symptoms of the initial head injury are gone. Second impact injury can result within a matter of days or weeks, or it can occur in the same game or competition if the athlete is not removed and treated after the first concussion. Neither impact has to be severe for second impact syndrome to occur. Symptoms usually occur immediately following the second impact and progress rapidly. In many cases, second impact syndrome can be fatal. In those cases where it is not fatal, you can expect the long-term effects to be similar to those of severe traumatic brain injury. Definition of Concussion A concussion is a type of traumatic brain injury (TBI). Concussions are 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 1

2 to, brief loss of consciousness, 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. These symptoms may be temporary or long lasting. Purpose The EISD Concussion Management Guidelines have been developed in accordance with Texas HB 2038 also cited as Natasha s Law. This document will update the UIL requirements for concussion management in student-athletes participating in activities under the jurisdiction of the UIL and will also provide information on compliance with Chapter 38, Sub Chapter D of the Texas Education Code (TEC). These requirements will help with the assessment, prevention, management and return to play protocol for student-athletes who have suffered a concussion. Prevention Strategies 1. Insist that safety comes first. 2. Teach and practice safe playing techniques. 3. Teach athletes the dangers of playing with a concussion. 4. Encourage athletes to follow the rules of play and to practice good sportsmanship at all times. 5. Make sure athletes wear the right protective equipment for their activity (such as helmets, padding, shin guards, and eye and mouth guards). 6. All headgear must be NOCSAE certified. 7. Make sure the headgear fits the individual, and are secured properly to the individual. 8. For all sports that require headgear, a coach or appropriate designate should check headgear before use to make sure air bladders work and are appropriately filled. 9. Padding should be checked to make sure they are in proper working condition. 10. The EISD Athletic Department recognizes the importance of neurocognitive baseline testing on athletes who compete in contact and collision sports. EISD has chosen to utilize the ImPACT concussion management system for neurocognitive testing. Student-athletes participating in contact and/or collision sports at the high school level will be given a baseline neurocognitive prior to the beginning of their respective season. 11. Education of administrators, coaches, parents and students to the importance of reporting and understanding the signs and symptoms of concussions. Concussion Oversight Team 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 2

3 approve a concussion oversight team. Each concussion oversight team shall establish a return-to-play protocol, based on peer reviewed scientific evidence, for a student's return to interscholastic athletics practice or competition following the force or impact believed to have caused a concussion. In developing a Return to Play (RTP) Protocol as required under TEC section , at a minimum, the local COT shall adopt the UIL Concussion Management Protocol, based on the guidelines from the National Federation of State High School Associations which have been mandated by the UIL Legislative Council and the UIL Medical Advisory Committee (MAC). If the local COT determines that it wishes to be more restrictive than the UIL Concussion Management Protocol, that is within their local discretion. According to TEC Section : The Concussion Oversight Team must include a physician and the EISD Athletic Trainers. Each member of the Concussion Oversight Team must have had training in the evaluation, treatment and oversight of concussions at the time of appointment or approval as a member of the team. The EISD Concussion Oversight Team members include: David W. Morledge, M.D. Austin Neurological Clinic James Allen, M.S., L.A.T. Vicki Stafko, M.S., A.T.C., L.A.T. Annual Form Acknowledging Concussion Information Texas law requires that a student may not participate in an interscholastic athletic activity for a school year until both the student and the student s parent or guardian or another person with legal authority to make medical decisions for the student have signed a form for that school year that acknowledges receiving and reading written information that explains concussion prevention, symptoms, treatment and oversight and that includes guidelines for safely resuming participation in an athletic activity following a concussion. The form must be approved by the University Interscholastic League. 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 to 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 3

4 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 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. Response to Suspected Concussion According to TEC Section , a student shall be removed from an interscholastic athletics practice or competition immediately if one of the following persons believes the student might have sustained a concussion during the practice or competition: 1. a coach; 2. a physician 3. a licensed health care professional; or 4. student s parent or guardian or another person with legal authority to make medical decisions for the student. If a student-athlete demonstrates signs or symptoms consistent with concussion, follow the Heads Up 4-Step Action Plan: The student-athlete shall be immediately removed from practice/game as noted above. Have the student-athlete evaluated by an appropriate health care professional as soon as practical. Inform the student-athletes parent or guardian about the possible concussion and give them information on concussion. 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 quickly the signs or symptoms of the concussion resolve and shall be kept from activity until a physician indicates that are symptom free and gives clearance to return to activity. A coach of an interscholastic athletics team may not authorize a student s return to play. Evaluation for Concussion 1. At the time of injury, the athletic trainer will administer one of the following assessment tests: a. Sports Concussion Assessment Tool b. Graded Symptom Checklist (GSC) c. Sideline Functional & Visual Assessments d. On-Field Cognitive Training e. Play-It-Safe Concussion Assessment f. SCAT2 Concussion Assessment g. Sports Safety Labs Concussion Assessment 4

5 h. ImCAT Concussion Awareness Tool i. American Academy of Neurology Reference Card 2. The athlete does not return to a practice or game if he/she has any symptoms that would indicate the possibility of suffering a concussion, as reported by: j. the student k. a coach l. a physician m. a licensed health care professional n. the student s parent or guardian or any person with the legal authority to make medical decisions for the student. 3. All athletes will be referred to a physician for evaluation. 4. Athlete/Parents will be given the EISD Home Instructions for Head Injuries 5. Athlete/Parents will be given the EISD Concussion Return to Play Protocol 6. Athlete/Parents will be given the UIL Concussion Management Protocol Return to Play Form 7. Any high school athlete that has sustained a head injury must report to the athletic trainers on a daily basis and middle school athletes must report to their coach and school nurse on a daily basis. High School athletes will be required to meet with the athletic trainers as soon as possible after the injury to schedule a time for postinjury neurocognitive testing. Testing will be done no earlier than hours after the initial injury. The EISD Athletic Department recognizes the importance of baseline testing on athletes who compete in contact and collision sports. EISD has chosen to utilize the ImPACT concussion management system for neurocognitive testing. 8. If in doubt an athlete is referred to physician and does not return to play. Concussion Management/Academic Modifications It may be necessary for individuals with a concussion to have both cognitive and physical rest in order to achieve maximum recovery in the shortest period of time. In addition to physical management, it may be necessary to modify/adjust academic requirements. 1. School Modifications a. School nurse will be notified of a student who has a concussion. b. School nurse will notify the student s teachers, assistant principals, counselors and folder teacher of students with a concussion. 5

6 c. School nurse will notify the student s teachers, assistant principals, counselors and folder teacher if any special accommodations such as limited computer work, reading activities, testing, assistance to class, etc. are necessary until symptoms subside. d. Students may only be able to attend school for half days or may need daily rest periods until symptoms subside. In some circumstances, the student may require homebound status for a brief period of time. e. If a student is given academic restrictions by the treating physician, the student must have a follow-up appointment within 4 weeks to have the academic restrictions re-evaluated. The student must present updated written information to the school nurse or counselor within 2 days of the re-evaluation. Return to Activity/Play Following a Concussion According to TEC Section : A student removed from an interscholastic athletics practice or competition under TEC Section (suspected of having a concussion) may not be permitted to practice or compete again following the force or impact believed to have caused the concussion until: 1. the student athlete has been evaluated; using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student s parent or guardian or another person with legal authority to make medical decisions for the student; 2. the student has successfully completed each requirement of the return-to-play protocol established under TEC Section necessary for the student to return to play. 3. the treating physician has provided a written statement indicating that, in the physician s professional judgment, it is safe for the student to return to play; and 4. the student and the student s parent or guardian or another person with legal authority to make medical decisions for the student: A. have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play protocol; B. have provided the treating physician s written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and C. have signed a consent form indicating that the person signing: i. has been informed concerning and consents to the student participating in returning to play in accordance with the return-to-play protocol; 6

7 ii. iii. iv. understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol; consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub.L. No ), of the treating physician s written statement under Subdivision (3) and, if any, the return-to-play recommendations of the treating physician; and understands the immunity provisions under TEC Section The UIL will provide standardized forms for the Return to Play procedure. EISD Return to Play Protocol 1. The student-athlete must provide the athletic trainer at the high school or school nurse at the middle school with a written release from the treating physician before the Return to Play Protocol can begin. EISD will not accept medical clearance from an emergency room physician. 2. The athlete must be symptom free at rest and with cognitive activities for at least 48 hours (including the completion of two full days of school). 3. High school student-athletes will be given a neurocognitive test after the concussion. All high school student-athletes who compete in contact and collision sports will have a baseline assessment done prior to their season. EISD utilizes the ImPACT program for this assessment. The student-athlete must pass the test with no red flags, have results within normal limits and present without symptoms to begin the Return to Play Protocol. This will apply to middle school student-athletes if they are given a neurocognitive test by their physician. 4. The return to play protocol will follow a supervised step-by-step activity progression. The progression will advance at the rate of one step per day. 5. The student-athlete will be monitored daily at school by an EISD athletic trainer at the high school and the school nurse at the middle school. 6. If at any point during the progression the athlete experiences any concussion symptoms, the athlete will wait 24 hours and start the progression again from the beginning. 7

8 Day 1 Day 2 Day 3 Day 4 Student-athlete has completed two full days of school and be symptomfree for at least 48 hours and student-athletes must also have results within normal limits and no red flags on neurocogntive test (if given). Student-athlete has completed 15 minutes of light aerobic exercise on an exercise bike or light jogging and is symptom free for 24 hours. No weight training, resistance training or any other exercise. Student-athlete has completed 25 minutes of moderate aerobic exercises which may include running at moderate intensity in the gym or on the field without a helmet or equipment and is symptom free for 24 hours. Non-contact training drills in full uniform. Student-athlete may begin weight lifting, resistance training and other exercises. Student-athlete is symptom free for 24 hours. Day 5 Full contact practice or training. Student-athlete is symptom free for 24 hours. Must have completed the UIL Concussion Management Return to Play Form and returned to the Athletic Trainer or School Nurse. Day 6 Return to full participation. Subsequent Concussion Any subsequent concussion requires further medical evaluation, which may include a physical examination prior to return to participation. Written clearance from a physician is required as outlined in TEC Section before any participation in UIL practices, games or matches. Unresolved Concussions Any student-athlete who has not been cleared by a physician or has not completed the Return to Play Protocol by the last day of the school year, will have to complete the protocol before participating in any school-related practice for the following school year. This includes any sports that may start before the first official day of school. Studentathletes must meet with the athletic trainers before the last day of school to discuss the procedure for completing the Return to Play for the following school year. Training Courses According to TEC Section : All EISD coaches of interscholastic athletic activities shall: 8

9 complete a two-hour UIL approved training course on evaluation, prevention, symptoms, risks and long-term effects of concussions at least every two years. All EISD athletic trainers shall: complete a training course on concussions approved by The Department of State Health Services Advisory Board of Athletic Trainers; or a course concerning the subject matter of concussions that has been approved for continuing education credit by the appropriate licensing authority for the profession. A physician who serves as a member of the concussion oversight team shall, to the greatest extent practicable, periodically take an appropriate continuing medical education course in the matter of concussions. Any licensed health care professional, other than an athletic trainer, who serves as a member of the concussion oversight team and is an employee, representative or agent of a school district or who serves on a volunteer basis must take: a two-hour UIL approved training course on the evaluation, prevention, symptoms, risks and long-term effects of concussions at least every two years; or complete a training course on concussions approved by The Department of State Health Services Advisory Board of Athletic Trainers; or a course concerning the subject matter of concussions that has been approved for continuing education credit by the appropriate licensing authority for the profession. 9

10 References University Interscholastic League Concussions and Concussion Management Protocol Requirements and Information National Federation of State High School Associations, Suggested Guidelines for Management of Concussion in Sports, January House Bill 2038~Natasha'sLaw,Texas Education Code, Chapter 38, Subchapter D, Prevention, Treatment, and Oversight of Concussions Affecting Student Athletes, June Guskiewicz, KM, et al. National Athletic Trainers position statement; management of sport-related concussion. Journal of Athletic Training 2004; 39: McCroryP., et al. Consensus statement of concussion in sport: the 3 rd International Conference on Concussion in Sport held in Zurich, November Journal of Athletic Training 2009; 44: American Academy of Neurology Sports Concussion Reference Card,

11 Eanes ISD Concussion Return to Play Protocol 1. The student-athlete must provide the athletic trainer at the high school or school nurse at the middle school with a written release from the treating physician before the Return to Play Protocol can begin. EISD will not accept medical clearance from an emergency room physician. 2. The student-athlete must be symptom free at rest and with cognitive activities for at least 48 hours (including the completion of two full days of school). 3. High school student-athletes will be given a neurocognitive test after the concussion. EISD utilizes the ImPACT program for this assessment. The student-athlete must pass the test with no red flags, have results within normal limits and present without symptoms to begin the Return to Play Protocol. This will also apply to middle school athletes if they are given a neurocognitive test by their physician. 4. The return to play protocol will follow a supervised step-by-step activity progression. The progression will advance at the rate of one step per day. 5. The student-athlete will be monitored daily at the high school by an EISD athletic trainer at the high school or the school nurse at the middle school. 6. If at any point during the progression the athlete experiences any concussion symptoms, the athlete will wait 24 hours and start the progression again from the beginning. Day 1 Day 2 Day 3 Day 4 Day 5 Student-athlete has completed two full days of school and be symptom-free for at least 48 hours and student-athletes must also have results within normal limits and no red flags on neurocognitive test (if given). Student-athlete has completed 15 minutes of light aerobic exercise on an exercise bike or light jogging and is symptom free for 24 hours. No weight training, resistance training or any other exercise. Student has completed 25 minutes of moderate aerobic exercises which may include running at moderate intensity in the gym or on the field without a helmet or equipment and is symptom free for 24 hours. Non-contact training drills in full uniform. May begin weight lifting, resistance training and other exercises. Student-athlete is symptom free for 24 hours. Full contact practice or training. Student-athlete is symptom free. Must have completed the UIL Concussion Management Return to Play Form and returned to the Athletic Trainer or Middle School Nurse. Day 6 Return to full play. I have read and understand the EISD Concussion Return to Play Protocol. Student Signature Date Parent Signature Date

12 Rev. April, 2012 CONCUSSION ACKNOWLEDGEMENT FORM Name of Student Definition of Concussion - means a complex pathophysiological process affecting the brain caused by a traumatic physical force or impact to the head or body, which may: (A) include temporary or prolonged altered brain function resulting in physical, cognitive, or emotional symptoms or altered sleep patterns; and (B) involve loss of consciousness. Prevention Teach and practice safe play & proper technique. Follow the rules of play. Make sure the required protective equipment is worn for all practices and games. Protective equipment must fit properly and be inspected on a regular basis. Signs and Symptoms of Concussion The signs and symptoms of concussion may include but are not limited to: Head ache, appears to be dazed or stunned, tinnitus (ringing in the ears), fatigue, slurred speech, nausea or vomiting, dizziness, loss of balance, blurry vision, sensitive to light or noise, feel foggy or groggy, memory loss, or confusion. Oversight - Each district shall appoint and approve a Concussion Oversight Team (COT). The COT shall include at least one physician and an athletic trainer if one is employed by the school district. Other members may include: Advanced Practice Nurse, neuropsychologist or a physician s assistant. The COT is charged with developing the Return to Play protocol based on peer reviewed scientific evidence. Treatment of Concussion - The student-athlete shall be removed from practice or competition immediately if suspected to have sustained a concussion. Every student-athlete suspected of sustaining a concussion shall be seen by a physician before they may return to athletic participation. The treatment for concussion is cognitive rest. Students should limit external stimulation such as watching television, playing video games, sending text messages, use of computer, and bright lights. When all signs and symptoms of concussion have cleared and the student has received written clearance from a physician, the student-athlete may begin their district s Return to Play protocol as determined by the Concussion Oversight Team. Return to Play - According to the Texas Education Code, Section : A student removed from an interscholastic athletics practice or competition under Section may not be permitted to practice or compete again following the force or impact believed to have caused the concussion until: (1) the student has been evaluated, using established medical protocols based on peer-reviewed scientific evidence, by a treating physician chosen by the student or the student s parent or guardian or another person with legal authority to make medical decisions for the student; (2) the student has successfully completed each requirement of the return-to-play protocol established under Section necessary for the student to return to play; (3) the treating physician has provided a written statement indicating that, in the physician s professional judgment, it is safe for the student to return to play; and (4) the student and the student s parent or guardian or another person with legal authority to make medical decisions for the student: (A) have acknowledged that the student has completed the requirements of the return-to-play protocol necessary for the student to return to play; (B) have provided the treating physician s written statement under Subdivision (3) to the person responsible for compliance with the return-to-play protocol under Subsection (c) and the person who has supervisory responsibilities under Subsection (c); and (C) have signed a consent form indicating that the person signing: (i) has been informed concerning and consents to the student participating in returning to play in accordance with the return-toplay protocol; (ii) understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return-to-play protocol; (iii) consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No ), of the treating physician s written statement under Subdivision (3) and, if any, the return-to-play recommendations of the treating physician; and (iv) understands the immunity provisions under Section Parent or Guardian Signature Date Student Signature Date

13 Eanes ISD Concussion Return to Learn Academic Accommodations Student Name: Return to school on (date): Grade: Sport: Healthcare Provider: Please check the recommended accommodations listed below for this student. Eanes ISD desires to provide appropriate care for the student with a concussion and will make every effort to follow the indicated recommendations. The student has the responsibility to communicate with their teachers and make arrangements to make up all required work, which may include homework, quizzes, tests, projects, etc. Recommended accommodations regarding specific courses, grading and special circumstances will be determined on a case by case basis. Yes No Modifications May attend school for half-days as tolerated May attend school for full days as tolerated May take Standardized Testing May take Tests May take Quizzes May take Tests with Extra Time May take Quizzes with Extra Time Testing in a quiet Environment Reduce homework/make-up work at this time Allow extra time for assignments to be completed Class notes/outlines given ahead of time to reduce multi-tasking demands Allow more passive work such as sitting/listening No IPAD/Computer use at this time Limit use of IPAD/Computer at this time 15 minutes on/15 minutes off Minimize multi-tasking with electronic devices during class Allow student to eat lunch in nurse/counselor s office to avoid noise of cafeteria Allow student to either lay head on desk or go to nurse if symptoms return Allow student to leave class early to avoid hallway noise/congestion Limit bright lights/noise May attend band/choir class and/or practice Concussion recovery time will vary with each student depending on contributing factors such as: type of injury, underlying student conditions, compliance with accommodations, initial symptoms score, etc. Middle School Students: Please give physician orders to the school nurse. Check in with the school nurse once a day until cleared for full participation. Physician Name (Printed): Phone Number: Physician Signature: Date:

14 Concussion Management Protocol Return to Play Form This form must be completed and submitted to the athletic trainer or other person (who is not a coach) responsible for compliance with the Return to Play protocol established by the school district Concussion Oversight Team, as determined by the superintendent or their designee (see Section (c) of the Texas Education Code). Student Name (Please Print) School Name (Please Print) Designated school district official verifies: Please Check The student has been evaluated by a treating physician selected by the student, their parent or other person with legal authority to make medical decisions for the student. The student has completed the Return to Play protocol established by the school district Concussion Oversight Team. The school has received a written statement from the treating physician indicating, that in the physician s professional judgement, it is safe for the student to return to play. School Individual Signature Date School Individual Name (Please Print) Parent, or other person with legal authority to make medical decisions for the student signs and certifies that he/she: Please Check Has been informed concerning and consents to the student participating in returning to play in accordance with the return to play protocol established by the Concussion Oversight Team. Understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return to play protocol. Consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No ), of the treating physician s written statement under Subdivision (3) and, if any, the return to play recommendations of the treating physician. Understands the immunity provisions under Section of the Texas Education Code. Parent/Responsible Decision-Maker Signature Date Parent/Responsible Decision-Maker Name (Please Print)