Section I. What is a Concussion?
A concussion is defined as a transient alteration in brain function without structural damage, but with other potentially serious long-term ramifications. In the event of a concussion, the brain sustains damage at a microscopic level in which cells and cell membranes are torn and stretched. The damage to these cells also disrupts the brain at a chemical level, as well as causing restricted blood flow to the damaged areas of the brain, thereby disrupting brain function. A concussion, therefore, is a disruption in how the brain works; it is not a structural injury. Concussions are difficult to diagnose because the damage cannot be seen. A MRI or CT Scan cannot diagnose a concussion, but they can help rule out a more serious brain injury to a student athlete. Because concussions are difficult to detect, student athletes must obtain medical approval before returning to athletics following a concussion.
Section II. Mechanism of Injury:
A concussion is caused by a bump, blow or jolt to the head or body. Any force that causes the brain to bounce around or twist within the skull can cause a concussion. A bump, blow or jolt to the head or body can be caused by either indirect or direct trauma. The two direct mechanisms of injury are coup-type and contrecoup-type. Coup-type injury is when the head is stationary and struck by a moving object such as another player’s helmet, a ball, or sport implement, causing brain injury at the location of impact. Contrecoup-type injury occurs when the head is moving and makes contact with an immovable or slowly moving object as a result of deceleration, causing brain injury away from the sight of impact. Indirect forces are transmitted through the spine and jaw or blows to the thorax that whip the head while the neck muscles are relaxed. Understanding the way in which an injury occurred is vital in understanding and having a watchful eye for athletes who may exhibit symptoms of a concussion so these student athletes can receive the appropriate care.
Section III. Signs and Symptoms:
Signs (what you see):
- Forgets plays
- Unsure about game, score, opponent
- Altered coordination
- Balance problems
- Personality change
- Slow response to questions
- Forgets events prior to injury (retrograde amnesia)
- Forgets events after injury (anterograde amnesia)
- Loss of consciousness (any duration)
Symptoms (reported by athlete):
- Nausea or vomiting
- Double vision/ blurry vision
- Sensitivity to light (photophobia)
- Sensitivity to noise (tinnitus)
- Feels sluggish
- Feels foggy
- Problems concentrating
- Problems remembering
- Trouble with sleeping/ excess sleep
- Seeing stars
- Vacant stare/ glassy eyed
- Inappropriate emotions
If any of the above signs or symptoms are observed after a suspected blow to the head, jaw, spine or body, they may be indicative of a concussion and the student athlete must be removed from play immediately and not allowed to return until cleared by an appropriate allied health professional.
Section IV. Management and Referral Guidelines:
1. When an athlete loses consciousness for any reason, the athletic trainer will start the EAP (Emergency Action Plan) by activating EMS; check ABC’s (airway, breathing, circulation); stabilize the cervical spine; and transport the injured athlete to the appropriate hospital via ambulance. If the athletic trainer is not available, the coach should immediately call EMS, check ABCs and not move the athlete until help arrives.
2. Any athlete who is removed from the competition or event and begins to develop signs and symptoms of a worsening brain injury will be transported to the hospital immediately in accordance with the EAP.
Worsening signs and symptoms requiring immediate physician referral include:
A. Amnesia lasting longer than 15 minutes
B. Deterioration in neurological function
C. Decreasing level of consciousness
D. Decrease or irregularity of respiration
E. Decrease or irregularity in pulse F. Increase in blood pressure
G. Unequal, dilated, or unreactive pupils
H. Cranial nerve deficits
I. Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding
J. Mental-status changes: lethargy, difficulty maintaining arousal, confusion, agitation
K. Seizure activity
L. Vomiting/ worsening headache
M. Motor deficits subsequent to initial on-field assessment
N. Sensory deficits subsequent to initial on-field assessment
O. Balance deficits subsequent to initial on-field assessment
P. Cranial nerve deficits subsequent to initial on-field assessment
Q. Post-Concussion symptoms worsen
R. Athlete is still symptomatic at the end of the game
3. After a student athlete sustains a concussion, the athletic trainer will use the Standardized Assessment for Concussion (SAC) to assess and document the student athlete’s concussion. The athletic trainer will also report on the student athlete’s signs and symptoms by using the Signs and Symptoms Check-List. On the signs and symptoms checklist, the athletic trainer will also check pulse and blood pressure of each student athlete with a suspected concussion. After the initial evaluation of a concussion, all signs and symptoms will be tracked on the computer using the ImPact Test.
4. Any athlete who is symptomatic but stable is allowed to go home with his/her parent(s)/guardian(s) following the head injury.
A. If the head injury occurs at practice, parent(s)/guardian(s) will immediately be notified and must come and pick up the student athlete and talk to the certified athletic trainer in person.
B. If the injury occurs at a game or event the student athlete may go home with the parent/guardian(s) after talking with the certified athletic trainer.
C. Parent(s)/guardian(s) will receive important information regarding signs and symptoms of deteriorating brain injury/function prompting immediate referral to a local emergency room as well as return to play requirements. Parent(s)/guardian(s), as well as student athletes, must read and sign the Concussion Information and Gradual Return to Play form and bring it back to the certified athletic trainer before starting with the return to play protocol.
V. Gradual Return to Play Protocol:
1. Student athletes, with the consent of their parent(s)/guardian(s), will start taking the ImPact Test (or other approved test identified by the School District). The ImPact Test is a tool that helps manage concussions, determine recovery from injury, and is helpful in providing proper communication between coaches, parents and clinicians. The ImPact Test is a neurocognitive test that helps measure student athletes’ symptoms, as well as test verbal and visual memory, processing speed and reaction time. It is mandatory for all student athletes to take the ImPact Test for a baseline score in accordance with Massachusetts State Law. The law states that all public schools must develop safety protocols on concussions and all public schools must receive information on past concussion history. The ImPact Test appears to be a promising tool in monitoring a student athlete’s prior concussions, as well as any future concussions.
2. Each student athlete will complete a baseline test at the beginning of their sport season. All student athletes and club cheerleading members will undergo ImPact testing. Student athletes will be retested every other year. If a student athlete plays more than one sport during the academic year, their test will remain valid. For example, if a soccer student athlete also plays basketball in the winter, the student athlete will not have to take the ImPact Baseline Test again in the winter. If a student athlete posts scores below the norm, the student athlete will be re-tested at another time with either the certified athletic trainer or school nurse. Student athletes cannot begin practice until a valid baseline score is obtained during their designated time to take the test.
A. At the beginning of every sport season, student athletes are required to complete a concussion history form and return it to the athletic department. This information will be recorded in the student information system for tracking purposes.
B. Following any concussion the athletic trainer must notify the athletic director and school nurses.
C. Following a concussion the student athlete will take a post-injury test within 24 to 48 hours following the head injury. STUDENT ATHLETES WILL NOT BE ALLOWED TO MOVE ON TO FUNCTIONAL/PHYSICAL TESTING UNTIL THEIR IMPACT TEST IS BACK TO THE BASELINE SCORE AND ASYMPTOMATIC. After a student athlete takes their first postinjury test, the student athlete will not be re-tested again for 5 days.
D. If, after the first post-injury ImPact test, the athlete is not back to his/her baseline the parent/guardian(s) will be notified, and the student athlete will be referred to their healthcare provider and must have the Concussion Information and Gradual Return to Play form signed by a physician, physician assistant, licensed neuropsychologist or nurse practitioner stating when the athlete is allowed to return to play.
E. Following a post-injury test, the certified athletic trainer will take the Concussion Information and Gradual Return to Play form signed by the parent(s)/guardian(s) and fill in the date of all post-injury tests taken by each student athlete.
F. The certified athletic trainer will also document the date on which the athlete is asymptomatic and sign the document agreeing that all the above statements are true and accurate.
G. Once the athlete starts on the exertional post concussion tests, the parent(s)/guardian(s) will be notified and the athlete will be sent home with all signed documents relating to head injury. At this time the parent/guardian(s) must bring the student athlete to a licensed physician, licensed neuropsychologist, licensed physician assistant, nurse practitioner or other appropriately trained or licensed healthcare professional to be medically cleared for participation in the extracurricular activity.
H. Student athletes who continue to exhibit concussion symptoms for a week or more must be evaluated by a physician before returning to play.
I. Once a student athlete’s post-injury test is back at the student athlete’s baseline score, the student athlete will go through 5 days of Exertional Post Concussion Tests. The student athlete must be asymptomatic for all functional and physical tests to return to play (RTP). All tests will be administered by a certified athletic trainer.
Exertional Post Concussion Tests:
A. Test 1: (30% to 40% maximum exertion): Low levels of light physical activity. This will include walking, light stationary bike for about 10 to 15 minutes. Light isometric strengthening (quad sets, UE light hand weights, ham sets, SLR’s, resistive band ankle strengthening) and stretching exercises.
B. Test 2: (40% to 60% maximum exertion): Moderate levels of physical activity. Treadmill jogging, stationary bike, or elliptical for 20 to 25 minutes. Light weight strength exercises (resistive band exercises UE and LE, wall squats, lunges, step up/downs. More active and dynamic stretching.
C. Test 3: (60% to 80% maximum exertion). Non-contact sports specific drills. Running, high intensity stationary bike or elliptical 25 to 30 minutes. Completing regular weight training. Start agility drills (ladder, side shuffle, zig-zags, carioca, box jumps, and hurdles).
D. Test 4: (80% maximum exertion). Limited, controlled sports specific practice and drills. E. Test 5: Full contact and return to sport with monitoring of symptoms.
Section VI. School Nurse Responsibilities:
1. Assist in testing all student athletes with baseline and post-injury ImPact testing.
2. Participate and complete the CDC training course on concussions. A certificate of completion will be recorded by the nurse leader yearly.
3. Complete symptom assessment when student athlete enters Health Office (HO) with questionable concussion during school hours. Repeat in 15 minutes.
4. Observe students with a concussion for a minimum of 30 minutes.
5. If symptoms are present, notify parent/guardian(s) and instruct parent/guardian(s) that student must be evaluated by an MD. (a) If symptoms are not present, the student may return to class.
6. If symptoms appear after a negative assessment, MD referral is necessary.
7. Allow students who are in recovery to rest in HO when needed.
8. Develop plan for students regarding pain management.
9. School nurse will notify teachers and guidance counselors of any students or student athletes who have academic restrictions or modifications related to their concussion.
10. Educate parents and teachers about the effects of concussion and returning to school and activity.
11. If injury occurs during the school day, inform administrator and complete accident/incident form.
12. Enter physical exam dates and concussion dates into the student information system.