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Concussion Safety Protocol

THE COLLEGE OF WOOSTER CONCUSSION SAFETY PROTOCOL


The College of Wooster is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. To this end, and in accordance with NCAA legislation, The College of Wooster has adopted the following Concussion Safety Protocol for all NCAA student-athletes. This protocol identifies expectations for institutional concussion management practices as they relate to: (1) the definition of sport-related concussion; (2) independent medical care; (3) preseason education; (4) pre-participation assessment; (5) recognition and diagnosis of concussion; (6) initial suspected concussion evaluation; (7) post-concussion management; (8) return-to-learn management; (9) return-to-sport management; (10) reducing head impact exposure; (11) reporting on concussion instances; and (12) written certificate of compliance signed by the athletics health care administrator.
 
1. Definition of Sport-Related Concussion 
There is no uniform definition of concussion. The Consensus Statement on Concussion in Sport, which resulted from the 6th international conference on concussion in sport, defines sport-related concussion as follows: 
 
Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged. 
 
No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Sport-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).  
 
2. Independent Medical Care
As required by NCAA Independent Medical Care legislation, team physicians and athletic trainers shall have unchallengeable autonomous authority to determine medical management and return-to-activity decisions, including those pertaining to concussion and head trauma injuries, for all student-athletes.
 
3. Preseason Education 
All NCAA student-athletes will be provided and allowed an opportunity to discuss concussion educational material (e.g., the NCAA Concussion Education Fact Sheet) or similar applicable material and will be required to sign an acknowledgement, on an annual basis and prior to participation, that they have been provided, reviewed, and understood the concussion education material.   
 
All coaches, team physicians, athletic trainers, directors of athletics and other  personnel involved in NCAA student-athlete health and safety decision making will be provided and allowed an opportunity to discuss educational material (e.g., the NCAA Concussion Education Fact Sheet) or other applicable material and will be required to sign an acknowledgment, on an annual basis, that they have been provided, reviewed and understood the concussion education material.  
 
At the beginning of each academic year, all faculty will be provided educational materials regarding academic accommodations that may be advisable to accommodate NCAA student-athletes who have sustained concussions. These educational materials will be provided by the NCAA annually.
 
4. Pre-Participation Assessment 
All NCAA student-athletes will undergo a pre-participation baseline concussion assessment. This assessment assumed individualized medical care, which means: Each athlete and each injury are different. Depending on the severity of prior injuries, the number of concussions, other individual concerns and based on the developing state of science, the team physician/primary health care provider should review each athlete’s history and consider discussing with the student-athlete concerns about concussion and repetitive head impact as warranted, including potential risks and benefits from playing sport. Such discussion allows the athlete to make an informed decision about their participation in sport. 
 
This pre-participation assessment will be conducted at The College of Wooster and, at a minimum, will include assessment for the following: 
 
  • History of concussion or brain injury, neurologic disorder, and mental health symptoms and disorders. *Will be updated annually*
  • Symptom evaluation. (Symptom evaluation within SWAY)
  • Cognitive assessment.  SWAY: Neuropsychological testing has been shown to be helpful in the evaluation and management of concussion. However, neuropsychological tests will not be used as a standalone measure to diagnose the presence or absence of a concussion as The College of Wooster uses a comprehensive assessment by its sports medicine staff.)
  • Balance evaluation. (SWAY)
 
The team physician will determine pre-participation clearance and/or the need for additional consultation or testing and will consider a new baseline concussion assessment at six months or beyond for any NCAA student-athlete with a documented concussion, especially those with complicated or multiple concussion history. Importantly, baseline testing may inform post-injury evaluation; however, student-athletes who have suffered a concussion may perform at the same level or even better than their baseline testing, as motivation and other factors may differ in post-concussion testing. Ultimately, baseline testing serves as one of many potential factors in making a clinical decision.

5. Recognition and Diagnosis of Concussion 
Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be present at all NCAA competitions in the following contact/collision sports: baseball; basketball; diving; field hockey; football; lacrosse; pole vault; soccer; softball; volleyball).
 
NOTE: To be present means to be on site at the campus or arena of the competition. The College of Wooster will ensure that such personnel will be from The College of Wooster, from the opposing team or will be contracted independently for the event. 
 
Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be available at all NCAA practices in the following contact/collision sports: baseball; basketball; diving; field hockey; football; lacrosse; pole vault; soccer; softball; volleyball).
 
NOTE: To be available means that, at a minimum, medical personnel can be contacted at any time during the practice via telephone, messaging, email, beeper or other immediate communication means and that the case can be discussed through such communication, and immediate arrangements can be made for the athlete to be evaluated. 
 
Any NCAA student-athlete that exhibits signs, symptoms, or behaviors consistent with concussion must be removed from practice or competition for evaluation. Examples of signs that warrant immediate removal from the field include: actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioral changes, amnesia.
 
Concussion evaluation:
  • Must be evaluated by an athletic trainer or team physician (or physician designee) with concussion experience.
  • Allow ample time (e.g., 10-15 minutes) when conducting a multi-modal screen (e.g., SWAY) to evaluate a potential concussion.
  • Must be removed from practice/play for the calendar day if concussion is confirmed or suspected.
  • May only return to play the same day if the athletic trainer, team physician or physician designee determines that concussion is no longer suspected after evaluation. Even in such cases, consider next day follow-up assessment because initial symptoms may not appear for several hours.
 
6. Initial Suspected Concussion Evaluation 
The initial concussion evaluation must include an immediate assessment/neurological screen for “red flags” or observable signs (as noted in the Concussion Emergency Action Plan below). The assessment may include a multi-modal evaluation as clinically indicated such as: 
 
  • Clinical assessment to rule out cervical spine trauma, skull fracture, intracranial bleed, or other catastrophic injury.
  • Symptom assessment. (Symptom evaluation within SWAY)
  • Physical and neurological exam. (SCAT 6 and/or Sports+ Protocol within SWAY and/or Visual Ocular Motor Screen) 
  • Cognitive assessment. (SCAT 6 and/or Sports+ Protocol within SWAY)
  • Balance exam. (SWAY)
 
If The College of Wooster sports medicine staff is asked to evaluate a visiting athlete for a team traveling without a Certified Athletic Trainer and they exhibit signs or symptoms of a concussion, a recommendation will be made to follow the NCAA guideline of no return to play. Ohio Athletic Training licensure regulations prevent athletic trainers from making specific return to play decisions for any injured visiting athletes.
 
A Concussion Emergency Action Plan is in place and includes:
 
A student-athlete must be immediately removed from play and assessed for possible transport to a local hospital/trauma center when any of the following signs/symptoms/behaviors are present:
 
  • Neck pain or tenderness.
  • Seizure or convulsion.
  • Double vision.
  • Loss of consciousness.
  • Weakness or tingling/burning in more than one arm or in the legs.
  • Deteriorating conscious state.
  • Vomiting.
  • Severe or increasing headache.
  • Increasingly restless, agitated or combative.
  • Glasgow Coma Scale Score <>
  • Visible deformity of the skull.
 
7. Post-concussion Management 
For all cases of diagnosed concussion, there must be documentation that post-concussion plan of care was communicated to both the student-athlete and another adult responsible for the student-athlete, in oral and/or written form. Because symptoms may evolve or manifest over time, for all suspected or diagnosed concussions, there will be in place a mechanism for serial evaluation of the student-athlete off-field the same day and up to 72 hours. 
 
There will be a subacute (three days to weeks post-injury) management plan in place that includes a mechanism for evaluation and monitoring of some or all the following:
 
  • Symptom evaluation.
  • Immediate and delayed memory.
  • Concentration.
  • Orthostatic vital signs.
  • Cervical spine assessment.
  • Neurological evaluation.
  • Balance and tandem gait assessment.
  • Modified VOMS.
 
In addition, the subacute management plan may consider evaluating for the following, as clinically indicated:
  • Screen for fear, anxiety or depression or other mental health issues.
  • Screen for sleep disturbance.
  • Graded aerobic exercise testing.
 
For all concussion management plans:
  • Consideration of symptom-limited, light aerobic physical activity within 24-48 hours (e.g., walking).
  • Consideration of reduced screen use in the first 48 hours after injury.
 
Re-Evaluation:
Any NCAA student-athlete with atypical presentation or persisting symptoms > 4 weeks will be re-evaluated by a physician in order to consider additional diagnoses, best management options, and consideration of referral. Additional diagnoses include but are not limited to: fatigue and/or sleep disorder; migraine or other headache disorders; mental health symptoms and disorders; ocular dysfunction; cervical and vestibular dysfunction; cognitive impairment and autonomic dysfunction including orthostatic intolerance and postural orthostatic tachycardia syndrome; pain. 
  
8. Return-to-Learn Management 
The vast majority of young adults have a full return-to-learn with no additional academic support by 10 days post-injury. Complete rest and isolation should be avoided, even during the initial 24-48 hours post-injury. Relative rest is important in the first 24 hours. For those student-athletes with persisting symptoms a more formal plan may be in order.
The return-to-learn concept should follow an individualized and step-wise process overseen by a point person(s) within the athletics department, who will navigate return-to-learn with the student-athlete and, in more complex cases of prolonged return-to-learn, work in conjunction with a multi-disciplinary team that may vary student-to-student depending on the specifics of the case but may include, but is not limited to: 
 
  • Team physician. 
  • Athletic trainers. 
  • Student Health Services (Psychologist/counselor, nurses). 
  • Neuropsychologist.
  • Medical specialists.
  • Faculty athletics representative. 
  • Academic Resource Center. 
  • Course instructor(s). 
  • College administrators. 
  • Office of disability services representative. 
  • Coaches. 
 
A student-athlete who has suffered a concussion will return to the classroom/studying only as tolerated with modification of schedule/academic accommodations, as indicated, with help from the identified point-person and the Academic Resource Center. The plan may address environment, physical, curriculum and/or testing adjustments. Additional campus resources will be engaged for cases that cannot be managed through schedule modification/academic accommodations. Campus resources will be consistent with the ADAAA and will include one of the following:
  • The Academic Resource Center
  • Office of Disability Services
  • ADAAA Office
 
A student-athlete will be re-evaluated by a team physician (or their designee) and members of the multi-disciplinary team, as appropriate, if concussion symptoms worsen with academic challenges or in the event of atypical presentation or persisting symptoms. 
 
9.  Return-to-Sport Management
Unrestricted return-to-sport should not occur prior to unrestricted return-to-learn for concussions diagnosed while the student-athlete is enrolled in classes. Complete rest and isolation should be avoided, even for the initial 24-48 hours. Relative rest is important in the first 24 hours. Final determination of unrestricted return-to-sport will be made by The College of Wooster team physician or their medically qualified designee following implementation of an individualized, supervised stepwise return-to-sport progression that includes:
 
  1. Symptom-limited activities of daily living.
    1. Discretion can be used by the health care provider to introduce mild aerobic activity during the transition period of returning to pre-concussion baseline status, so long as there is no more than mild or brief (<1 hour)="" exacerbation="" of="">
  2. Aerobic exercise with light resistance training.
    1. As tolerated [no more than mild or brief (<1hour) exacerbation="" of="" symptoms].="">
      1. Light (up to approximately 55% maximum heart rate); then
      2. Moderate (up to approximately 70% maximum heart rate).
        1. Examples include walking, swimming, riding a stationary bike, and/or body weight exercises for at least 15 minutes.
  3. Individual sport-specific exercise and activity without any increased risk of inadvertent head impact exposure.
    1. As tolerated [no more than mild or brief (<1hour) exacerbation="" of="">
 
*Proceed to step 4 only after resolution of signs and symptoms related to the current concussion, including with and after physical exertion.
 
  1. Non-contact practice with progressive resistance training.
    1. If asymptomatic with non-contact drills and resistance training, then;
  2. Unrestricted practice or training.
    1. If asymptomatic with full practice/training, then;
  3. Unrestricted return-to-sport.
 
The above stepwise progression will be supervised by a health care provider with expertise in concussion. It is typical for each step in the progression to last at least 24 hours and any NCAA student-athlete diagnosed with a concussion by medical personnel must be cleared by a physician before being permitted to return to full participation.
 
NOTE: If at any point the student-athlete becomes symptomatic (more symptomatic than baseline), the team physician or physician designee will be notified, and adjustments will be made to the return-to-sport progression. *For example, exercise stops with more than minimal increase of pre-exercise level.
 
10. Reducing Head Impact Exposure
The College of Wooster is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. To this end and in accordance with NCAA association-wide policy, The College of Wooster will reduce student-athlete head impact exposure in a manner consistent with Interassociation Recommendations: Preventing Catastrophic Injury and Death in Collegiate Athletics and Consensus statement on concussion in sport: the 6th. International Conference on Concussion in Sport. For example:
  • The College of Wooster will adhere to existing ethical standards in all practices and competitions.
  • Using playing or protective equipment (including the helmet) as a weapon will be prohibited during all practices and competitions.
  • Deliberately inflicting injury on another player will be prohibited in all practices and competitions.
  • All playing and protective equipment (including helmets), as applicable, will meet relevant equipment safety standards and related certification requirements.
  • The College of Wooster will keep the head out of blocking and tackling in contact/collision, helmeted practices and competitions.
  • The College of Wooster will emphasize education of proper technique to reduce head impact exposure for all contact and collision sports, with a special emphasis in the pre-season.
  • The College of Wooster will adhere to policies and rules in sport that limit the number and duration of contact practices and activities in contact-collision sports.
  • Consideration of participation in neuromuscular training warm-up programs.
 
11. Reporting of Concussion Instances
In accordance with the Arrington Settlement, all instances of diagnosed sport-related concussions in student-athletes and their resolution will be reported to the NCAA on an annual basis pursuant to policies and procedures maintained by the Committee on Competitive Safeguards and Medical Aspects of Sports. Reporting will be completed by the  Athletics Health Care Adminstrator.