Western Dubuque Cmmunity Schl District - Cncussin Guideline Fr the purpses f this guideline, the term student athlete is defined as a Western Dubuque Cmmunity Schl District (WDCSD) student participating in extracurricular activities. This guideline helps the safety f student athletes wh have sustained a cncussin r mild traumatic brain injury (MTBI) in a WDCSD spnsred extracurricular activity. This guideline is designed t return cncussed athletes t cmpetitive sprts/activity in a manner that will reduce the likelihd f Secnd Impact Syndrme. The guideline utlined belw will assist the human brain t heal and repair itself befre anther pssible injury can ccur. N guideline can guarantee against future incidents, but this guideline will help increase the likelihd that the cncussed brain is healed befre they return t participatin, thus making Secnd Impact Syndrme much less likely. March 4, 2010 - The Natinal Federatin f State High Schl Assciatins changed their psitin n cncussin t the fllwing: Effective with the 2010 high schl ftball seasn, any player wh shws signs, symptms r behavirs assciated with a cncussin must be remved frm the game and shall nt return t play until cleared by an apprpriate health-care prfessinal. WDCSD Cncussin Guideline A student/athlete with signs and symptms f a cncussin, r a student/athlete believed t have sustained a MTBI, will be remved frm participatin until evaluated and cleared by a qualified health care prfessinal specifically trained in cncussin evaluatin and management. The WDCSD emplys Certified Athletic Trainers (ATCs) wrking under the WDCSD Team Physician. The ATCs and WDCSD Team Physician will serve as the qualified individuals in this area within the WDCSD. This des nt exclude ther health care prfessinals frm evaluating r treating cncussins within the WDCSD student athlete ppulatin utside f the schl setting. If parents/guardians chse t take their student athlete fr evaluatin t ther health care prfessinals utside f the schl setting, it is encuraged that thse health care prfessinals evaluating and treating cncussins be qualified and trained in the area f cncussin and MTBI management. All suspected cncussins, r thse shwing signs r symptms f having a cncussin (listed belw) will be remved frm cmpetitin/practice. They then will be evaluated as sn as pssible by the district ATCs r WDCSD Team Physician. If thse health care prfessinals are nt available, the parents will be ntified and suggested t take their sn/daughter t a family physician fr evaluatin r t the emergency rm if symptms dictate s. If anther medical prfessinal such as a MD/DO perfrm an evaluatin and treatment at the emergency rm r family physicians ffice the qualified health care prviders rders will be reviewed and fllwed unless the WDCSD Team Physician r the ATCs feel the athlete needs further evaluatin and screening. The WDCSD Medical Staff will be acting in the best interest f the athlete and the schl district. The District will be using the Immediate Pst-Cncussin Assessment and Cgnitive Testing (ImPACT) sftware. ImPACT is a cncussin evaluatin tl that has been used by NCAA Divisin I schls and ther prfessinal sprts. Athletes will take a pretest n ImPACT and that data is saved. In the event f a suspected r diagnsed cncussin the athlete will be given an after injury test and the scres will be evaluated by the WDCSD Medical Team. This will act as anther tl fr the WDCSD Team Physician and ATCs t use as a guide t safe return t participatin (RTP). ImPACT Tests will nt be the sle determining factr fr RTP decisins. All WDCSD High Schl Ftball Players (all levels), Varsity Vlleyball, Varsity Bys and Girls Basketball Players, Varsity Bys and Girls Sccer Players, and Varsity Wrestlers will be given the ImPACT Test. If the athlete is deemed t have suffered a cncussin, the athlete will nt be allwed t return t participatin until cleared by the ATCs, WDCSD Team Physician, r ther qualified health care prfessinal. The athlete must fllw the return t participatin (RTP) prtcl and prcedure as appears in this guideline. Assessment and evaluatin f the athlete will take place and a cmparisn f pre and pst injury ImPACT scres will be perfrmed t help determine RTP status. N student-athlete will be allwed t return t participatin withut fllwing the RTP prtcl and prcedure. Fllwing a cncussin, the athlete will be administered a pst injury ImPACT test and the scres will be evaluated by the WDCSD Team Physician and/r the ATCs. If there is n baseline test available fr cmparisn the scres will be cmpared t a natinal data base standard. If a parent wuld like the scres made available t them t take t their family physician they can make a verbal r written request t the ATC. The WDCSD Team Physician and the ATCs (wrking directly under WDCSD Team Physician) will have ultimate return t participatin authrity. The Team Physician and the ATCs will take int cnsideratin all ther health care prviders qualificatins and directins and will make a determinatin as t the athletes return t play status. The WDCSD Team Physician and the ATCs may agree t fllw ther health care prviders scripts r chse t verrule thse prviders if believed t be in the best interest f the schl district r the athlete. The WDCSD Medical Staff will nt verrule a restrictive nte unless the parents/guardians request a secnd pinin frm the WDCSD Team Physician and will then fllw the WDCSD Team Physician s findings and directin. The ATCs will nt verrule a cnservative r mre cautius nte in any circumstance. 1
Definitin f Cncussin: Cncussin is defined as a cmplex pathphysilgical prcess affecting the brain, induced by traumatic bimechanical frces. Several cmmn features that incrprate clinical, pathlgical and bimechanical injury cnstructs that may be utilized in defining the nature f a cncussive head injury include: 1. Cncussin may be caused either by a direct blw t the head, face, neck r elsewhere n the bdy with an impulsive frce transmitted t the head. 2. Cncussin typically results in the rapid nset f shrt-lived impairment f neurlgic functin that reslves spntaneusly. 3. Cncussin may result in neurpathlgical changes, but the acute clinical symptms largely reflect a functinal disturbance rather than a structural injury. 4. Cncussin results in a graded set f clinical symptms that may r may nt invlve lss f cnsciusness. Reslutin f the clinical and cgnitive symptms typically fllws a sequential curse; hwever, it is imprtant t nte that, in a small percentage f cases, pst-cncussive symptms may be prlnged. 5. N abnrmality n standard structural neurimaging studies is seen in cncussin. The preceding definitin is frm the Cnsensus Statement n Cncussin in Sprt 3 rd Internatinal Cnference n Cncussin in Sprt Held in Zurich, Nvember 2008. Sign and Symptm f a Cncussin: Signs bserved Appears t be dazed r stunned Is cnfused abut assignment Frgets plays Is unsure f game, scre, r ppnent Mves clumsily Answers questins slwly Lses cnsciusness (even temprarily) Shws behavir r persnality change Frgets events prir t hit (retrgrade amnesia) Frgets events after hit (antergrade amnesia) Additinal Cncussin Infrmatin: Signs reprted by athlete Headache Nausea Balance prblems r dizziness Duble r fuzzy visin Sensitivity t light r nise Feeling sluggish Feeling "fggy" Change in sleep pattern Cncentratin r memry prblems Secnd Impact Syndrme (SIS) is als a very real cncern and can be ptentially catastrphic. Accrding t the Center fr Disease Cntrl and Preventin (CDC) a repeat cncussin that ccurs befre the brain recvers frm the first, usually with a shrt perid f time (hurs, days, r weeks), can slw recvery r increase the likelihd f having lng term prblems. In rare case, repeat cncussins can result in brain swelling, permanent brain damage, and even death. The CDC refers t this mre serius cnditin as Secnd Impact Syndrme. SIS in shrt is suffering a secnd MTBI r cncussin while the brain is recvering frm an initial MTBI r cncussin and thus ptentially leading t a higher level f brain damage and catastrphic cnsequences. SIS is believed t have been the cause f apprximately 30-40 deaths ver the last decade. The risk f SIS is real, and fllwing a gradual return t participatin prtcl after sustaining a MTBI r cncussin can greatly reduce the chances f this ptentially life threating cnditin. In additin, with every MTBI r cncussin there is a risk f develping Pst-Cncussin Syndrme (PCS). Accrding t the May Clinic, PCS is a cmplex disrder in which a cmbinatin f pst-cncussin symptms may last fr weeks and smetimes mnths after the injury that caused the initial cncussin. Symptms f PCS may include but are nt limited t chrnic headaches, fatigue, sleep difficulties, persnality change, increased irritability, increased emtinal feelings, sensitivity t light and nise, dizziness, and deficits in shrt-term memry and general academic functining. PCS can be very disabling fr an athlete, and may be permanent in sme cases. The majrity f athletes wh experience MTBI r cncussin are likely t recver fully withut experiencing lng term detrimental effects f MTBI r cncussin. 2
Detailed Return t Participatin (RTP) Prtcl This prcedure will start after injury. The athlete will mve frm Step t Step until cmpletin f the prtcl befre full return t participatin (RTP) is granted. If every step is passed withut cmplicatins, an athlete culd ptentially return t full game participatin in 6 Days (See Table-1). Hwever, this is the best case scenari and is ften nt the case when dealing with cncussin and MTBI. If symptms linger r resurface during the RTP prtcl it will delay return and prgressin f the athlete thrugh the steps. WDCSD persnnel, Team Physician, r the ATCs will cntact the athlete s family regardless f severity f cncussin r MTBI. Prgressin past Step 1 nly ccurs if athlete reprts and shws n signs r symptms f cncussin r Pst-Cncussin Syndrme. An athlete will nt advance r prceed in the prcess with signs and symptms f cncussin. If symptms ccur r persist anytime in the prtcl the athlete may be referred back t WDCSD Team Physician r family physician. If this ccurs the athlete will nt prgress any further in the RTP prtcl. Step One Preseasn ImPACT Testing will ccur befre participatin t establish a baseline. Athlete is initially evaluated by ATCs r WDCSD Team Physician r qualified health care prfessinals and determined t have a cncussin r MTBI. Once diagnsed with cncussin r MTBI, The parents/guardians will be ntified f the injury. The athlete may be mnitred at frequent intervals fr deteriratin f symptms fr the remainder f the day. Shuld symptms deterirate; the student-athlete will be taken t an apprpriate medical care facility. As part f that initial evaluatin the athlete will be required t take a pst injury ImPACT test the day after the cncussin injury ccurred. The scres will be cmpared t the baseline scres f the pre-injury test r natinal data base standard. Fllwing ImPACT Testing, the athlete will be evaluated by the ATCs r the WDCSD Team Physician. If the athlete has symptms they will be held frm all physical activity and mental exertin. This culd mean the absence f schl and classrm activities. The ATCs will cmmunicate with schl administratin, schl nurse, and teachers t reprt the athlete s cnditin and cgnitive abilities if necessary. The ATCs r the WDCSD Team Physician may recmmend time ff frm schl t allw the brain t heal. Once the athlete is asymptmatic (they lack signs and symptms f a cncussin) they will be prgressed t Step Tw prviding a minimal f 2 Days has passed frm time f initial injury. An athlete culd stay n Step One as lng as symptms remain. If an athlete has increase signs r wrsening symptms the athlete will be referred back t a physician r t a specialist. If an athlete remains the same fr mre than 7 days and des nt wrsen r imprve the athlete will als be referred back t a physician r specialist at that time. 3
Step Tw Athlete will take secnd ImPACT Test fllwing injury. This is t be dne n sner than 2 Days pst initial injury, and the athlete must be asymptmatic t take the secnd test. If the athlete s scres are cmparatively equal t baseline scres and the athlete remains asymptmatic the ATCs r WDCSD Team Physician will determine whether t prgress the athlete t physical activity and the RTP prtcl as dictated in Step Three. If the athlete s scres are nt cmparatively equal r symptms increase during testing, the ATCs r the WDCSD Team Physician will make a determinatin as hw t prgress the athlete. This may include anther day f rest befre prceeding t Step 3. The WDCSD Medical Team can cnclude it is nt in the best interest f the athlete r the district t prgress the athlete, even if the athlete claims t be asymptmatic and their scre are cmparatively equal. This may ccur mre frequently in thse individuals with a cncussin histry r ther mental r cgnitive cnditins that may delay healing. Previus cncussin histry, ImPACT scres, medical evaluatin results, current medicatins the athlete may be using, and ther cgnitive r physical cmplicatins will be cnsidered in making the decisin t prgress the athlete in the RTP prtcl. ImPACT scres are nt the sle determining factr in RTP prgressin. Step Tw can prgress t Step Three in the same day if athlete is asymptmatic and has cmparatively equal ImPACT scres. Step Three Athlete is ready fr Physical Activity. If symptms result at any time during the prgressin, the athlete will autmatically fall back t the previusly passed day, and must be asymptmatic frm wake-up t time f test befre attempting the prgressins previus day s physical r mental tests. Physician cnsultatin may als ccur if this ccurs. See Example 1 fr further clarificatin. Physical Activity Prgressin (By Days) Day 1 Light cardivascular exercise n statinary equipment, Heart rate t stay belw 70% f max heart rate. (If n symptms ccur they can prgress t Day 2) Day 2 - Athlete will be put thrugh higher intensity cardivascular using a nn-statinary means, such as running r swimming and may r may nt be specific t their sprt (If n symptms ccur they can prgress t Day 3) Day 3 Strenuus cardivascular wrkut which may be specific t psitin in sprt. If cntact sprts n cntact drills allwed but may participate in nn-cntact drills. (If n symptms ccur they may prgress t Day 4) Day 4 Return t nrmal practice. Full cntact allwed with n restrictins in practices. Athlete is nt released fr game r cmpetitin play. The head cach and ATC will determine what is cnsidered a full cntact unlimited practice. 4
Step Fur In this step the athlete will underg a final evaluatin and screening and be returned t full participatin withut restrictins. This may include a final ImPACT test. The athlete must have cmpleted a full cntact unlimited practice prir t being released t participated in any game r cmpetitin. Day 5 Full and Unlimited participatin in Games and Matches. Example - 1: Athlete cmpletes a STEP 3 - Day 2 wrkut and fllwing experiences increase symptms, the athlete will first wait until they are asymptmatic and then have t perfrm the Day 1 test again t prgress t Day 2. On the day f the repeated Day 1 test the athlete must be asymptmatic frm early mrning wake-up t time f test the same day. This means the athlete culd nt wake up the next day with a headache (symptms) and then prceed t try the repeated Day 1 cardivascular exercise in the afternn when the headache subsides. Physicians may be cnsulted if this ccurs. 5
Summatin f Return t Participatin Prcedure The fllwing infrmatin and chart represents the best case scenari after a MTBI r cncussin injury fr return t participatin status. Athletes must be asymptmatic t prgress past Day 1 (Step 1), and must cntinue t be asymptmatic thrughut the prgressin t Full Release. If an Athlete experiences symptms f cncussin at any time they will nt be allwed t prgress t the next step. Specifically if any athlete experiences symptms during Day 2 5 they will mve back 1 day and must wake up asymptmatic the day they plan t take the previus day s physical/mental tests. At any time symptms may dictate an athlete t be mved back mre than ne Day in the prgressin t ensure athlete safety. A referral back t a physician r specialist may als be dictated. In additin the WDCSD Team Physician r WDCSD ATCs can halt prgressin if it is determined t be in the best interest f the schl district r student athlete, even if athlete states t be asymptmatic and passes all ImPACT testing. Table - 1 Pst-Cncussin Summatin f RTP Prtcl Day 1 Day 2 Day 3 BEST CASE SCENERIO Day 4 Day 5 Day 6 Day 7 Cncussin Occurred ImPACT Test 1 Rest - N Physical r Mental Activity ATHLETE IS ASYMPTOMATIC ImPACT Test 2 Light Statinary Cardivascular Exercise <70% Mvement Based Cardivascular Exercise High Intensity Sprt Specific Drills (NO CONTACT) Full Practice and Cntact Activities Impact Test 3 (NO GAMES) Full Release All Activities GAME PLAY Mnday Tuesday Wednesday Thursday Friday Saturday Sunday Tuesday Wednesday Thursday Friday Saturday Sunday Mnday Wednesday Thursday Friday Saturday Sunday Mnday Tuesday Thursday Friday Saturday Sunday Mnday Tuesday Wednesday Friday Saturday Sunday Mnday Tuesday Wednesday Thursday Saturday Sunday Mnday Tuesday Wednesday Thursday Friday Sunday Mnday Tuesday Wednesday Thursday Friday Saturday STEP 1 -Preseasn ImPACT Testing Day 0 -Athlete Sustains, r is Diagnsed with Cncussin -Athlete Remved Frm Participatin Day 1 -Athlete Re-Evaluated -Pst Injury 1 ImPACT Test -Rest Mental/Physical STEP 2 Day 2 -Only if Athlete Asymptmatic (Remain at Day 1 Until Ttally Asymptmatic) -If Asymptmatic => Pst Injury 2 ImPACT Test => STEP 3 STEP 4 Day 2 Cntinued -If Passed Pst Injury 2 ImPACT Test => Light Statinary Cardivascular Exercise <70% Max -If Nt Passing => Re-Evaluate Factrs Pssible N Exercise r Stay at Step 1 Day 3 -If Asymptmatic => Higher Intensity Cardivascular Exercise with Mvement -If Nt Asymptmatic => Re-Evaluate and Return t Day 2 Day 4 -If Asymptmatic => Prgress t Increase Intensity Sprt Specific Training (NO CONTACT) -If Nt Asymptmatic => Re-Evaluate and Return t Day 3 Day 5 -If Asymptmatic => Full Cntact Practice (NO GAMES) -If Nt Asymptmatic => Re-Evaluate and Return t Day 4 6
Day 6 -If Asymptmatic => FULL RELEASE NO RESTRICTIONS -If Nt Asymptmatic => Re-Evaluate and Return t Day 5 PHYSICAL EDUCATION NOTE Patient Name: Date f Evaluatin: The student named abve has suffered a cncussin and is currently under the care f a licensed medical prfessinal. He/She is nt permitted t participate in any cntact sprt activity until frmally cleared by the licensed medical prfessinal. Physical Educatin Class Recmmendatins: NO physical educatin class (please als cnsider having the student sit in a spt where he/she is nt at risk fr getting hit by thers/sprting balls/etc. Yu may wish t send student t library /study hall/nurse s ffice t rest during the gym perid.) Restricted Physical Educatin Class Activity as specified belw: Light nn-cntact exertin nly (e.g., walking, light statinary bike Up t mderate nn-cntact, nn-risk exertin nly (e.g., light jg) Up t heavy nn-cntact, nn-risk exertin nly(e.g.,sprints,running) NO grup sprt, n cntact sprt (e.g., n basketball,hckey, ddgeball) ***If sme level f exertin is permitted, activities may be mdified t be nn-cntact. Fr example, if the class is playing basketball, the cncussed athlete may nt participate in games r scrimmage, but may practice individual shting r dribbling, which wuld nt pse a risk fr cntact. Signature 7
Cncussin Awareness fr Student-Athletes, Parents r Guardians and Schl Persnnel Western Dubuque Cmmunity Schl District shall develp plicies that assure student-athletes, parents r guardians, and schl persnnel and receive an infrmatinal sheet describing: The nature and risk f a cncussin r head injury The criteria fr remval frm participatin and return t participatin The risks f nt reprting injury and cntinuing t play Apprpriate academic accmmdatins fr diagnsed cncussin victims Infrmatinal materials used shall emanate frm prgrams such as, but nt limited t: Heads Up t Schls: Knw Yur Cncussin ABC s Heads Up: Cncussin in Yuth Sprts Heads UP: Cncussin in High Schl Sprts IHSAA-Sprts Medicine -Cncussin Inf IGHSAA-Cncussin Inf Best Practices: In-Service training Team meetings r practice segment Team pre-participatin dcuments Student-Athlete/Parent rientatin Cach/Parent preseasn meeting Athletic trainer tips Frmal/Infrmal seminars 8
Remval and Return-t Participatin After an apprpriate medical assessment, any student-athlete suspected f sustaining a cncussin shall immediately be remved frm practice r play. The student-athlete shall nt return until cleared by a licensed health care prvider authrized t prvide sprts physical examinatins and trained in the evaluatin and management f cncussins. Ntificatin f pssible head injury(figure 5) Medical clearance fr gradual return t sprts participatin fllwing cncussin (Figure 6) Graduated return t participatin prtcls (Figures 7,8,9) Yuth Sprts Prgrams use f Schl Prperty Yuth sprts prgrams seeking t use schl facilities must vertify distributin f cncussin infrmatin t parents r guardians and receive verifiable acknwledgement f receipt. 9
has successfully cmpleted Cncussin in Sprts What Yu Need T Knw / / Date f cmpletin WDCCSD Authrized Health Care Prvider 10
Student-Athlete Date f Injury Sprt Parent/Guardian Name Hme Phne Ntificatin f Prbable Head Injury Dear Parents: Based n ur bservatin and/r incident described belw, we believe yur sn/daughter exhibited signs and symptms f a cncussin while participating in. It is imprtant t recgnize that blws t the head can cause a variety f injuries ther than cncussins (e.g., neck injuries, mre serius brain injuries). Please be sure t see yur physician as sn as pssible fr any ther medical cncerns. Descriptin f Incident/Injury: When t Seek Care Urgently. If yu bserve any f the fllwing signs, call yur dctr r g t yur emergency department immediately. -Headaches that wrsen -Very drwsy, can t be awakened -Can t recgnize peple r places -Seizures -Repeated vmiting -Increasing cnfusin -Neck pain -Slurred speech -Weakness/numbness in arms/legs -Unusual behaviral change Significant irritability -Less respnsive than usual Cmmn Signs & Symptms. It is cmmn fr a student with a cncussin t have ne r many symptms. Physical: Cgnitive Emtinal Headache Fatigue/Feeling tired Feeling mentally fggy Irritabilty Visual Prblems Sensitivity t light/nise Feeling slwed dwn Sadness Nausea/Vmiting Numbness/Tingling Difficulty remembering Mre emtinal Dizziness Difficulty cncentrating Nervusness Balance Prblems Sleep: Drwsiness Sleeping less than usual Sleeping mre than usual Truble falling asleep Please feel free t cntact me if yu have any questins. I can be reached at:. 11 Emplyee Name and Title Date