University of Central Arkansas Concussion Protocol and Management Plan

University of Central Arkansas Concussion Protocol and Management Plan 5/2018 It is often reported that there is no universal agreement on the standard definition or nature of concussion; however, agreement does exist on several features that incorporate clinical, pathologic, and biomechanical injury constructs associated with head injury: 1. Sport related concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. 2. Sport related concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, signs and symptoms and signs may evolve over a number of minutes to hours. 3. Sport related concussion may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4. Sport related concussion results in a range of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged. (McCrory et al.2017) A. DIAGNOSIS A student-athlete who exhibits any one of the following signs or symptoms after contact with the head, or other parts of the body which transmits an impulsive force to the head during activity, will be considered as having a concussion and will be diagnosed and treated as having a Concussion Signs and Symptoms 1. Loss of consciousness or fluctuations in consciousness 2. Balance and coordination problems 3. Mental confusion 4. Memory and concentration difficulties 5. Self-reported symptoms (SRS)- (To include but not limited to) a. Headache b. Dizziness c. Ringing in the ears (tinnitus) d. Nausea e. Sensitivity to light and sound f. Fatigue or drowsiness g. Visual disturbances h. Emotional state (sadness, irritable or anxious) 1

B. MODIFIERS 5/2018 The following modifying factors for concussions may influence the diagnosis and management of concussions and may also predict the potential for prolonged symptoms. Concussion Modifiers (Broglio et al. 2014) Factors Symptoms Signs Sequelae Temporal Threshold Age Comorbidities and Premorbidities Medication Behaviour Sport Modifier - Number, Duration (> 10d), Severity - Prolonged LOC (> 1min), Amnesia - Concussive convulsions - Frequency: repeated concussion over time - Timing: concussion close together in time - Recency : recent concussions or TBI - Repeated concussions occurring with progressively less impact force or slower recovery after each successive - Child or adolescent (<18y old) - Migraines or family history of, depression, or other mental health disorders, ADHD, learning disabilities, Sleep disorders. - Psychoactive drugs, anticoagulants - Dangerous style of play - High-risk activity, contact and collision C. HOME CARE PROTOCOL Once a student-athlete has been diagnosed with a concussion and same day referral to a physician/hospital has not been warranted at the time of the evaluation, the home care protocol will be initiated. An adult will be identified as the caregiver to monitor the student-athlete with the concussion for 24hrs or until re-evaluation by the certified athletic trainer. The athletic trainer will review the concussion checklist with the caregiver and student-athlete to identify signs and symptoms and complications of the concussion and to help identify if signs and symptoms are getting worse. The caregiver will be instructed to call 911 or transport the student-athlete to the nearest hospital immediately if any of the signs and symptoms on the concussion checklist appear or worsen. The caregiver and student-athlete will be instructed on the importance of complete physical and cognitive rest until asymptomatic. The caregiver and student-athlete will be instructed to report to the certified athletic trainer the following day for re-evaluation. 2

D. EDUCATION 5/2018 The athletic training department will be charged with educating the coaching staff, studentathletes, athletic director and team physician(s) as well as staff athletic trainers annually on concussions. A signed acknowledgement will be obtained from each party demonstrating their understanding of the institution concussion management plan. 1. Athletic Trainer(s) a. The head athletic trainer will educate the staff athletic trainer(s) on the institution concussion protocol. b. The athletic trainer(s)will be given the NCAA fact sheet on concussion and educated in the protocol for concussion management and return-to-play guidelines as well as return-to-learn guidelines. c. The athletic trainer(s) will be given a copy of the institution concussion protocol and management plan and provide a signed acknowledgement they have been educated on 2. Coaches a. The athletic trainer for each sport will educate the coaches on concussion and the importance of identifying student-athletes early with a concussion so appropriate management can be initiated. b. Coaches will be given the NCAA fact sheet on concussion and educated in the protocol for concussion management and return-to-sport guidelines as well as returnto-learn guidelines. c. Coaches will be given a copy of the institution concussion protocol and will be given an opportunity to ask questions. d. Coaches will provide a signed acknowledgement they have been educated on concussion during their emergency action plan education session with their sport athletic trainer. e. Coaches involved in contact and collision sports will be reminded to make every effort to reduce head trauma in their sport through use of proper technique and reducing gratuitous contact during practice. 3. Student-Athletes a. The student-athlete will be educated on concussion definition, post -concussion syndrome, second impact syndrome and common symptoms that occur during a b. The student athlete will be given NCAA concussion educational material fact sheet during their initial pre-participation physical exam and educated on the importance of notifying the athletic training staff if they suspect they experience any signs and symptoms of a c. The student-athlete will sign a Concussion Notification and Agreement Policy form during their initial pre-participation physical examination. d. The student athlete will be given an opportunity to ask questions and have their questions answered by a member of the UCA athletic training staff. 4. Athletic Director a. The head athletic trainer will educate the athletic director on the institution concussion protocol and management plan. b. The Athletic Director will be given the NCAA fact sheet on concussion and educated in the protocol for concussion management and return-to-play guidelines as well as return-to-learn guidelines. c. The Athletic Director will be given a copy of the institution concussion protocol and provide a signed acknowledgement they have been educated on 5. Team Physician(s) a. The head athletic trainer will educate the team physician(s) on the institution concussion protocol and management plan. b. The team physician(s)will be given the NCAA fact sheet on concussion and educated in the protocol for concussion management and return-to-play guidelines as well as return-to-learn guidelines. c. The team physician(s) will be given a copy of the institution concussion protocol and provide a signed acknowledgement they have been educated on 3

E. BASELINE TESTING The intent of baseline testing is to aid the clinician in the post-injury management process by providing data that represent an athlete s brain function in an uninjured state. (Broglio et al.2014) 1. Those student-athletes at a high risk of concussion (i.e. contact or collision sports) will undergo baseline testing. 2. Student-athletes with a significant concussion history as documented in their health history questionnaire or other relevant comorbidity, such as attention-deficit hyperactivity disorder, may be considered for baseline testing. 3. The UCA team physician may determine any pre-participation requirements for sport clearance and has the authority to dictate the need for additional diagnostic testing. 4. An additional baseline test will be considered for those student-athletes with a documented diagnosed 5. Baseline testing of the student-athlete may include but not limited to any one of the following assessments: o Sport Concussion Assessment Tool (SCAT) o ImPact computer testing o Vestibular-Occular Motor Screening o Paper Pencil Test F. MANAGEMENT The following procedures will be used as guidelines for management of the student-athlete following a 1. An athletic trainer will be required to be at all NCAA varsity sport competitions at UCA. a. When an athletic trainer is present (i.e. contact/collision sport competitions) they will examine the student-athlete immediately and at 10 min. intervals for the development of amnesia, post-concussion signs and symptoms (PCSS) (i.e. mental status abnormalities, balance difficulties) and self- reported symptoms (SRS) (i.e. head-ache, visual disturbances, dizziness, tinnitus, etc.) b. An athletic trainer may not be present at all sport practices, individual position workouts, weight lifting or conditioning sessions. When the athletic trainer is not present at the event, an athletic trainer will be available for telecommunication and will evaluate the student-athlete as soon as reasonably possible. The attending coach, (being educated on concussions and EAP) will be charged with removing the student-athlete from the activity if they suspect the student-athlete as having a concussion or symptoms of a 2. Once the student-athlete has been suspected of a concussion by a coach, or diagnosed with a concussion by the sport athletic trainer, he/she will be removed from participation and disallowed to return-to-play or return-to-learn (classroom activities) that same day. 3. Sport Concussion Assessment Tool (SCAT) administered as soon as possible. a. Assessment will include: i. Self-reported symptoms ii. Immediate memory and cognition iii. Balance and Coordination iv. Cervical and skull trauma v. Neurological exam 4. ImPact computer testing will be administered as soon as possible 5. The student-athlete will be instructed to modify/decrease physical and cognitive activity. 6. The student-athlete will be advised to be with an adult when sent home for serial monitoring of signs of evolving intracranial pathology. Home care instructions for the attending adult are found in section C. 7. Re-evaluation of the student-athlete using SCAT/ImPact for development of, or worsening of amnesia, PCSS and SRS. 8. Re-evaluation and retesting of post-concussion symptoms and SRS will be based on severity of symptoms and the athletic trainers and physician(s) discretion on the need for retesting. 9. Re-evaluation and retesting should allow a minimum of 24hrs between testing. 10. Referral to a physician or hospital will be based on the following guidelines and signs and 4

symptoms. Note: student-athletes will be evaluated on specific modifiers in section B that may alter management. a. Day of Injury Referral i. Loss of consciousness >1min. or fluctuations in consciousness ii. Deterioration in cranial nerve assessment iii. Deterioration in PCSS (SCAT) iv. Deterioration in amnesia (SCAT) v. Deterioration in balance and coordination (SCAT) vi. Mental status and behavior worsens vii. Unequal, dilated or nonreactive pupils viii. Decrease or irregularity in respiration ix. Decrease or irregularity in pulse x. Cervical spine trauma xi. Skull fracture xii. Signs of intracranial bleeding xiii. Seizures xiv. Slurred speech or inability to speak xv. Repetitive emesis (vomiting) xvi. Glasgow Coma Scale < 13. b. Delayed Referral i. Any signs and symptoms from day of injury develop. ii. PTA >24hrs (SCAT)(ImPact) iii. PSS do not improve or worsen within 24hrs or PCSS >7days (SCAT)(ImPact) G. RETURN-TO-PLAY 1. Once the SCAT and ImPact score represents data from the student-athletes baseline SCAT and ImPact and the student-athlete has been asymptomatic of amnesia (PTA), PCSS, and SRS for a minimum of 24hrs, a graduated return-to-play protocol can be initiated. 2. Return to play protocol will be based on the duration and severity of the self -reported symptoms and post-concussion syndrome symptoms. a. i.e. a student-athlete who experiences self- reported symptoms > 7 days and/or severe post-concussion symptoms, may require to be asymptomatic for more than 24hrs before the return to play protocol will be initiated and may also require a more gradual return to play protocol. 3. It should be understood that concussion modifiers in section B may alter the return to play or learn protocol. 4. Each student-athlete must complete the required return-to-play protocol as designated by the team physician(s) and their sport athletic trainer before they will be released for full activity. 5. UCA team physician and/or the UCA certified athletic trainer who is under the direction of the team physician will have unchallengeable authority in all return to play decisions. Graduated return-to-play (RTP) strategy Stage - Aim Activity Goal 1 - Symptom limited activity Daily activities that do not provoke symptoms Gradual return to work/school 2 - Light Aerobic Walking, stationary bike, no resistance HR 3 - Sport Specific Light Sport Drills, no impact Movement 4 - Non-contact training Progress to more difficult drills Coordination 5 - Full Contact Practice Participate in normal practice Confidence/functional skills 6 - Return to sport Normal game play n/a (McCrory, et al. 2017) 5

H. RETURN-TO-LEARN 1. Decreasing cognitive activity is as important as decreasing physical activity after a student-athlete receives a Student-athletes diagnosed with a concussion may need academic accommodations to assist in their recovery. 2. No student-athlete will be allowed to return to classroom activity the same day of a The student-athlete may need a follow-up by the team physician if academic activity continues to increase their symptoms. 3. The extent of academic support and accommodations is based on the severity of the concussion, self-reported symptoms and SCAT/ImPact evaluation from the athletic trainer. The sport athletic trainer will communicate and collaborate with university instructors/professors and the Director of Athletic Academic Advising on any needed or suggested academic accommodations to help the student-athlete progress safely and fully into their academic coursework. Accommodations may include but not limited to the following: a. Excused absence from class b. Extension of assignments c. Postponement or staggering of tests or extended test taking time d. Accommodation for oversensitivity to light, noise or both. e. Excuse from coursework requiring physical exertion f. Use of a reader for testing or reader for note taking and assignments g. Use of preferential classroom seating to lessen distraction 4. Additional campus resources will be sought for those student-athletes when the above accommodations/modifications are unsuccessful. To include but not limited to: a. Student Counseling Services b. Office of Disability and Resource Center I. FOLLOW-UP 1. After the student-athlete has returned to full activity, an athletic trainer will follow-up with them for any return of PCSS. The student-athlete will be required to complete a concussion follow-up form which will assist the athletic trainer in determining if the student-athlete is having any residual post-concussion symptoms from their 2. The student-athlete will be educated on post-concussion syndrome and the symptoms associated with this condition. The concussion follow-up will be administered throughout the athletic season and/or academic year as deemed necessary by the certified athletic trainer. 3. If the student-athlete has been found to be experiencing any post-concussion syndrome symptoms, they will be referred to the UCA Team Physician and/or Team Neurologist for further evaluation. The evaluation may include but not limited to (Concussion re-evaluation, neuropsychological testing, counseling, psychological evaluation, diagnostic testing, referral to office of disability and resource center, etc.) J. STUDENT-ATHLETE RESPONSIBILITY 1. The student-athlete is educated on concussion, symptoms of a concussion and return to play guidelines at the beginning of their athletic career and again once they are diagnosed with a 2. The student-athlete has a responsibility to notify an athletic trainer if they suspect they have received a concussion or notice symptoms of a concussion during practice or competition. This also includes any symptoms of concussion they feel has not healed or symptoms that have returned. 3. The student-athlete is expected to be fully transparent in their signs and symptoms and fully cooperative when being evaluated by the athletic trainer and/or physician at the time of their suspected 6

K. DISQUALIFICATION 1. The decision to disqualify a student-athlete for the season or career will be made by the UCA team physician(s) and athletic training staff. The decision will be based on several factors including but not limited to, number of concussions, duration of signs and symptoms (PCSS), several episodes of loss of consciousness and/or severity of one LOC episode with prolonged PCSS and PTA, increased sensitivity to concussions, as well as all modifiers noted in section E. 2. Guidelines used to decide on disqualification after repeated concussions include but are not limited to the following: a. A student-athlete who receives a concussion with prolonged PCSS and PTA. b. A student-athlete who receives three (3) concussions in the same season. c. A student-athlete who receives several (>2), concussions with prolonged recovery of PTA and PCSS. d. A student-athlete who has exhibited more than two LOC episodes during each e. Abnormal neuroimaging results. f. Any involvement of, change, or abnormal respiration or cardiac function. 3. The UCA Team Physician(s) will have full discretion on disqualifying a student-athlete for the season or career. L. REFERENCES The following references were used in the development of the UCA Concussion Protocol and Management Plan: 1. Broglio, SP, Cantu RC.,Gioia GA.,Guskiewicz KM., Kutcher J., Palm M.,McLeod TCM.,; National Athletic Trainers Association Position Statement: Management of Sport Related Concussion. Journal of Athletic Training. 2014; 49(2): 245-265. 2. Covassin,T., Stearne,D., Elbin,R., Concussion History and Postconcussion Neurocognitive performance and symptoms in Collegiate Athletes. Journal of Athletic Training. 2008; 43(2) 119-124. 3. McCrory, P., et al; Consensus Statement on Concussion in Sport: The 5 th International Conference on Concussion in Sport, Berlin,2017. British Journal of Sports Medicine 5. Onate,JA., Beck,BC., Van Lunen,BL., On-Field Testing Environment and Balance Error Scoring System Performance During Preseason Screening of Healthy Collegiate Baseball Players. Journal of Athletic Training. 2007; 42(4): 446-451. 6. Valovich McLeod, TC., The Value of Various Assessment Techniques in Detecting the Effects of Concussion on Cognition, Symptoms, and Postural Control. Journal of Athletic Training. 2009; 44(6); 663-665. 7