Concussion Assessment, Management, and Return to Play Guidelines

Concussion Assessment, Management, and Return to Play Guidelines The following policy and procedures on neurocognitive baseline testing and subsequent assessment and management of concussions as well as return to play guidelines has been developed in accordance with the goal of the Athletic Training Department at John F. Kennedy High School provide quality healthcare services and assure the well-being of each student-athlete at John F Kennedy High School (JFKHS). Purpose The JFK high School Athletic Training Department recognizes that sport related concussion pose a significant health risk for JFKHS athletes. Therefor the Athletic Training Department has implemented policies and procedures to deal with the assessment, management, and return to play (RTP) considerations for student-athletes who have sustained a concussive episode. In addition, the Athletic Training Department also recognizes the importance of baseline testing on studentathletes who participate in sports which are recognized as contact or collision and/or who have a history of concussions upon entering athletic participation at JFKHS. A gradual RTP protocol will all be used in conjunction with sound clinical judgment and on an individualized basis to determine when it is safe for an athlete to return to competition. Definition Concussion - A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Direct blow or impulsive forces transmitted to the head Typically results in rapid onset of neurological impairments Functional injury: Not a structural injury May or may not include loss of consciousness (LOC) Not identifiable on standard imaging (CT, MRI) Mild Traumatic Brain Injury (mtbi) All concussions are a form of mtbi, however not all mtbi's are concussions. The terms mtbi and concussion should NOT be used interchangeably. Post Concussion Syndrome A set of symptoms which may last for weeks, months, or years following a concussion Second Impact Syndrome Rare condition when an athlete sustains a second head injury before

Signs and Symptoms of Concussion symptoms from the first have resolved, often fatal Certified athletic trainers and athletic training students need to be aware of the potential signs and symptoms of concussion to properly diagnosis the injury and begin formal management. Symptoms can take seconds to hours to develop following a concussive injury. Physical Cognitive Emotional Sleep Headache Difficulty remembering Behavioral changes Sleep more than usual Fatigue Difficulty concentrating Irritability Sleep less than usual Dizziness Feeling slowed down Sadness Drowsiness Photophobia Feeling in a fog Feeling emotional Trouble falling asleep Sensitivity to noise Slowed reaction times Nervousness Nausea Altered attention Anxiety Balance problems Amnesia LOC Vision difficulty ImPACT Testing: All Athletes will be required to have a baseline ImPACT test on file with the athletic training department. ImPACT testing will be performed every 2 years. Incoming freshman, juniors, and transfer students will be required to have a baseline test on file. There will be group ImPACT testing performed by the athletic trainer each year, in general, grouped by team. If an athlete has recently been tested by a Doctor, the athlete may be excused from testing provided the athletic trainer is given appropriate copies of the test. Before the test is given, athletes will be given an ImPACT pamphlet to bring home and have parents sign. If the athletes do not have their signed forms with them on the day of testing they will not be allowed to take the test and must reschedule to take the test during the other team s testing times, if space allows. Athletes who do not have ImPACT tests on file will not be allowed to participate in contact (any practice that requires a helmet or pads). As per the Performance Physical Therapy and the district, post-concussion ImPACT testing cannot be performed by the athletic training room, they are performed by the doctor during concussion rehabilitation. The concussion evaluation procedures are highlighted below.

Management In any circumstance where a concussion is suspected, the athlete will not be allowed to return to play that day. In the event of immediate concerns regarding the athlete s mental state, the athletic trainer will err on the side of caution until further evaluations can be obtained and/or the athlete is examined by a physician. The recommendations in this document for the management of concussion are based on a review of the medical literature including, but not limited to, Consensus Statement on Concussion in Sport The 4 th International Conference on Concussion in Sport held in Zurich (2012), The National Athletic Trainers Association Position Statement: Management of Sport-related Concussion, The 6 th Annual Sports-Related Conference on Concussion and Spine Injury and NCAA Sports Medicine Handbook, California Interscholastic Federation Guidelines, and AB 25 Assembly Bill and CA State Law AB2127. The youth sports concussion bill AB 25 states if a school district elects to offer an athletic program, the district shall comply with the following: o An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the activity for the remainder of the day, and shall not be permitted to return to the activity until he or she is evaluated by a licensed health care provider, trained in the management of concussions, acting within the scope of his or her practice. The athlete shall not be permitted to return to the activity until he or she receives written clearance to return to the activity from that licensed health care provider. o On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the athlete and the athlete's parent or guardian before the athlete's initiating practice or competition. o This section does not apply to an athlete engaging in an athletic activity during the regular school day or as part of a physical education course required pursuant to subdivision (d) of Section 51220. CA State Law 2127 (effective 1/1/15) states that RTP cannot be sooner than 7 days after evaluation BY A PHYSICIAN (MD/DO) who has made diagnosis of a concussion. The rest of the RTP protocol outlined by CA state law 2127 is outlined later. On Field / Sideline Evaluation 1) In all cases in which a concussion is suspected the athlete will be removed from athletic participation and a formal evaluation will take place. The athlete will NOT be allowed further participation on the day of the injury. a) Athlete removed from field utilizing c-spine precautions and transported to emergency department if presents with: i) Prolonged LOC and/or

ii) Focal neurologic defect and/or iii) Significant alteration or deterioration in mental status. b) Athlete conscious and alert will be removed to sideline for evaluation 2) Sideline evaluation a) A concussion evaluation will be performed as well as any of the following (time and situation permitting): i. SCAT 5 ii. Injury history (Hx), date/time, previous concussion Hx recorded, etc. iii. Verbal symptom checklist iv. Neurologic exam v. Cranial Nerve Assessment vi. Upper and lower quarter screening vii. Neurocognitive test Standardized Assessment of Concussion (SAC) viii. Modified BESS test ix. Coordination examination x. Finger to nose task xi. Gait coordination xii. Tandem walk ATR Clinic Evaluation b) Following the sideline evaluation, continue serial monitoring every 5 minutes until symptoms stabilize, improve, or a determination is made that the athlete should be referred to the hospital. Hold helmet (if applicable). 1) Any athlete who has sustained a concussion will be required to report to the Athletic Training Room (ATR) or equivalent if traveling for more formal evaluation 2) Clinic evaluation will consist of: a) Initial Clinic Evaluation form b) SCAT5 3) If warranted, physician evaluation will also be scheduled within 48 hours of the injury 4) Prior to leaving the ATR the athlete will be given a home instructions sheet, and given instructions on what to do should their condition deteriorate

Treatment / Rehabilitation 1) Athletes who sustain a concussion will be instructed to rest, meaning total rest: Follow up Evaluation(s) a) Physical rest i) No athletic participation ii) No recreational exercise b) Cognitive rest i) Limit academic work ii) Limit video games iii) Limit text messaging c) When warranted, notification will be sent to the Athletic Director who will notify the principal and necessary teachers requesting the student be granted academic accommodations as needed during their recovery. 1) Athletes who have sustained a concussion will be required to follow up with the team athletic trainer daily until cleared by a medical professional 2) Follow up evaluation will consist of completing the \ Management Follow up Form and any of the following: a) Graded symptom check list b) Neurologic exam c) Modified BESS test d) SCAT5 3) Once the athlete is asymptomatic and has returned to baseline values with concussion evaluation procedures they may be cleared by a physician for RTP if the parents so choose.

Grading a) The Performance Physical Therapy/ District policy is if an athlete who is suspected of a concussion visits a doctor (whether their Primary or otherwise), the athlete is required to be referred to a concussion specialist, and only a concussion specialist can clear the athlete using the required documentation (unless otherwise directed). 4) Once the athlete is cleared by the athletic trainer or a concussion specialist and is back to baseline values they may begin a supervised graduated RTP protocol. The grading of concussions prior to their resolution is not appropriate and therefore concussions will not be given a grade or number until the concussion has completely resolved. Many of the factors in grading a concussion depend on the severity of symptoms and duration which cannot be known until the athlete is asymptomatic both at rest and with exertion. Special Considerations Medications Are usually not needed but in some cases may be needed when considering sleep and headaches. If the athletic trainer or physician allows the athlete to take medication, only Tylenol (acetaminophen) should be used. Aspirin and NSAIDs should NOT be used by the athlete. *note that the athlete should not be using medication when assessing symptoms and RTP. Physician / Neurologist Clearance Will be required for the following situations prior to RTP: Multiple Concussions, in season and/or career Duration of symptoms greater than 10 days LOC greater than 1 minute Convulsions Two concussive episodes close together, and/or recent TBI Athlete suffering from migraine, depression, ADHD, sleep disorder, or other mental health issue Athlete currently taking psychoactive drugs, anticoagulants Return to Play Considerations RTP protocol following a concussion follows a stepwise progression required and outlined by CIF Concussion Return to Play (RTP) protocol. CA State law states that the return to play (competition) CANNOT BE SOONER than 7 days after evaluation by a physician (MD/DO) who has made the diagnosis of a concussion. The athlete must be symptom free and returned to baseline values before beginning this progression. The athlete will complete each level and progress to the

next only if they remain asymptomatic both at rest, during and following provocative exercise for 24 hours. Each step will take 24 hours. Should the athlete become symptomatic during the progression, they will drop back to the previous asymptomatic level and try to progress after a 24 hour period of rest has passed and a follow up BESS Test. Level 1 Light aerobic exercise = increase heart rate (walking, stationary bike, sit ups, etc.) Level 2 Sport specific exercises (ex: skating, running, cutting, jumping) Level 3 Non-contact drills (complex training drills, passing, catching, resistance training) Level 4 Full contact practice (full medical clearance) Level 5 Return to play (game) The Full RTP Guidelines are shown below. The Graduated RTP must be completed before an athlete returns to full competition. A certified ATC must initial each stage as it is successfully passed. Stages 1 to II-D take a minimum I of 6 days to complete. The athlete must be back to normal academic activities before beginning stage II The Athlete must complete one full practice without restrictions (stage III) before completing in the first game. 1. After Stage I, the athlete cannot pass more than I stage per day (or longer if a physician instructs it). 2. If Symptoms return at any stage in the process, immediately stop the physical activity and follow up with the ATC or physician. Then if the athlete is symptom free the next day, return to the previous stage where the symptoms had not occurred and continue the progression. 3. Seek further medical attention if the athlete cannot pass a stage after 3 attempts due to concussion symptoms, or if you feel uncomfortable during the progression.

Continued post-concussive symptoms, prior concussion history and any diagnostic testing results along with neurocognitive testing and physical exam, will be utilized by the team physician and athletic trainer in establishing a timeline for an athlete's return to activity. It is important to note that this timeline could last over a period of days to weeks or months, or potential medical disqualification from athletics. All cases will be handled on an individualized basis. The decision by the Team Physician for all cases of an athlete's return to activity is final. Summary The JFK High School Athletic Training Department is proactive in the prevention, recognition, and management of concussion to limit the risks of concussions associated with athletics as well as to limit the potential catastrophic and long

term risks associated with sustaining a concussion. The management and return to play decisions will remain in the realm of clinical judgment on an individualized basis by both the certified athletic trainer and the team physician. JFKHS Initial Clinic Concussion Evaluation

Name: Sport: YOG: Date of Injury: Time of Injury: Date of Exam: Time of Exam: Mechanism of Injury: Does patient have a history of prior concussion: No / Yes, When Current Symptom None Mild Moderate Severe Headache 0 1 2 3 4 5 6 Nausea 0 1 2 3 4 5 6 Vomiting 0 1 2 3 4 5 6 Dizziness 0 1 2 3 4 5 6 Drowsiness 0 1 2 3 4 5 6 Numbness / Tingling 0 1 2 3 4 5 6 Feeling slowed down 0 1 2 3 4 5 6 Feeling like in a fog 0 1 2 3 4 5 6 Difficulty concentrating 0 1 2 3 4 5 6 Difficulty remembering 0 1 2 3 4 5 6 Visual changes (blurry, double) 0 1 2 3 4 5 6 Ringing in the ears 0 1 2 3 4 5 6 Sensitivity to light 0 1 2 3 4 5 6

Sensitivity to noise 0 1 2 3 4 5 6 Sadness 0 1 2 3 4 5 6 Irritability 0 1 2 3 4 5 6 Emotional 0 1 2 3 4 5 6 Nervous / Anxious 0 1 2 3 4 5 6 Fatigue 0 1 2 3 4 5 6 Total Symptom Score: Loss of consciousness: No / Yes, Duration Amnesia: Pre Injury: No / Yes, Duration Post Injury: No / Yes, Duration Pupils equal: No / Yes Pupils reactive: No / Yes Cranial Nerve Exam: Normal / Abnormal, Findings Motor screening: Normal / Abnormal, Findings Sensory screening: Normal / Abnormal, Findings Deep Tendon Reflex: Normal / Abnormal, Findings Modified BESS test: # Errors Coordination: Normal / Abnormal