Athletic Training: Concussions


ImPACT TEST Protocol & Procedures

Grand Island Senior High School: Athletic Department Protocol and Procedures for Management of Sports-Related Concussion

Medical management of sports-related concussion is evolving. In recent years, there has been a significant amount of research into sports-related concussion in high school athletes. Grand Island Senior High School has established this protocol to provide education about concussion for athletic department staff and other school personnel. This protocol outlines procedures for staff to follow in managing head injuries, and outlines school policy as it pertains to return to play issues after concussion.

Grand Island Senior High School seeks to provide a safe return to activity for all athletes after injury, particularly after a concussion. In order to effectively and consistently manage these injuries, procedures have been developed to aid in insuring that concussed athletes are identified, treated and referred appropriately, receive appropriate follow-up medical care during the school day, including academic assistance, and are fully recovered prior to returning to activity.

In addition to recent research, two (2) primary documents were consulted in developing this protocol. The "Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004" [i](referred to in this document as the Prague Statement), and the "National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion" [ii] (referred to in this document as the NATA Statement).

This protocol will be reviewed on a yearly basis, by the GISH medical staff. Any changes or modifications will be reviewed and given to athletic department staff and appropriate school personnel in writing.

All athletic department staff will attend a yearly in-service meeting in which procedures for managing sports-related concussion are discussed.

Contents:

  1. Recognition of concussion
  2. Management and referral guidelines for all staff
  3. Procedures for the Certified Athletic Trainer (ATC)
  4. Guidelines and procedures for coaches
  5. Follow-up care during the school day
  6. Return to play procedures

 

I. Recognition of concussion

  • Common signs and symptoms of sports-related concussion
    • Signs (observed by others):
      • Athlete appears dazed or stunned
      • Confusion (about assignment, plays, etc.)
      • Forgets plays
      • Unsure about game, score, opponent
      • Moves clumsily (altered coordination)
      • Balance problems
      • Personality change
      • Responds slowly to questions
      • Forgets events prior to hit
      • Forgets events after the hit
      • Loss of consciousness (any duration)
    • Symptoms (reported by athlete):
      • Headache
      • Fatigue
      • Nausea or vomiting
      • Double vision, blurry vision
      • Sensitive to light or noise
      • Feels sluggish
      • Feels "foggy"
      • Problems concentrating
      • Problems remembering
    • These signs and symptoms are indicative of probable concussion. Othercauses for symptoms should also be considered.
  • Cognitive impairment (altered or diminished cognitive function)
    • General cognitive status can be determined by simple sideline cognitive testing.
      • AT may utilize ImPACT, or other standard tool for sideline cognitive testing.
      • Coaches should utilize the basic UPMC cognitive testing form.

II. ImPACT neuropsychological testing requirements

  • ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is a research-based software tool utilized to evaluate recovery after concussion. It was developed at the University of Pittsburgh Medical Center (UPMC). ImPACT evaluates multiple aspects of neurocognitive function, including memory, attention, brain processing speed, reaction time, and post-concussion symptoms.
    • Neuropsychological testing is utilized to help determine recovery after concussion.
  • All athletes at Grand Island Senior High School are required to take a baseline ImPACT test prior to participation in sports at GISH (usually freshman year).
  • Athletes in collision and contact sports (as defined by the American Academy of Pediatrics classifications) are required to take a "new" baseline test prior to participation their junior year.

III. Management and Referral Guidelines for All Staff

  • Suggested Guidelines for Management of Sports-Related Concussion[iii]
    • Any athlete with a witnessed loss of consciousness (LOC) of any duration should be spine boarded and transported immediately to nearest emergency department via emergency vehicle.
    • Any athlete who has symptoms of a concussion, and who is not stable (i.e., condition is changing or deteriorating), is to be transported immediately to the nearest emergency department via emergency vehicle.
    • An athlete who exhibits any of the following symptoms should be transported immediately to the nearest emergency department, via emergency vehicle.
      • deterioration of neurological function
      • decreasing level of consciousness
      • decrease or irregularity in respirations
      • decrease or irregularity in pulse
      • unequal, dilated, or unreactive pupils
      • any signs or symptoms of associated injuries, spine or skull fracture, or bleeding
      • mental status changes: lethargy, difficulty maintaining arousal, confusion or agitation
      • seizure activity
      • cranial nerve deficits
    • An athlete who is symptomatic but stable, may be transported by his or her parents. The parents should be advised to contact the athlete's primary care physician, or seek care at the nearest emergency department, on the day of the injury.
      • ALWAYS give parents the option of emergency transportation, even if you do not feel it is necessary.

IV. Procedures for the Certified Athletic Trainer (AT)

  • The AT will assess the injury, or provide guidance to the coach if unable to personally attend to the athlete.
    • Immediate referral to the athlete's primary care physician or to the hospital will be made when medically appropriate (see section II).
    • The AT will perform serial assessments following recommendations in the NATA Statement, and utilize the sideline ImPACT, if available.
      • The Athletic Trainer will notify the athlete's parents and give written and verbal home and follow-up care instructions.
  • The AT will notify the school nurse of the injury, prior to the next school day, so that the school RN can initiate appropriate follow-up in school immediately upon the athlete's return to school.
    • The AT will continue to provide coordinated care with the school RN, for the duration of the injury.
    • The AT will communicate with the athlete's guidance counselor regarding the athlete's neurocognitive and recovery status, if needed.
  • The AT is responsible for administering post-concussion ImPACT testing.
    • The initial post-concussion test will be administered within 48-72 hours post-injury, whenever possible.
      • Repeat post-concussion tests will be given at appropriate intervals, dependent upon clinical presentation.
    • The AT will review post-concussion test data with the athlete and the athlete's parent.
      • ImPACT data will be forwarded to a doctor trained in ImPACT for review and consultation.
    • The AT will forward testing results to the athlete's treating physician, with parental permission and a signed release of information form.
    • The AT or the athlete's parent may request that a neuropsychological consultant review the test data. The athlete's parents will be responsible for charges associated with the consultation.
    • The AT will monitor the athlete, and keep the School Nurse informed of the individual's symptomatology and neurocognitive status, for the purposes of developing or modifying an appropriate health care plan for the student-athlete.
    • The AT is responsible for monitoring recovery & coordinating the appropriate return to play activity progression.
    • The AT will maintain appropriate documentation regarding assessment and management of the injury.

V. Guidelines and procedures for coaches:

  • RECOGNIZE, REMOVE, REFER
    • Recognize concussion
      • All coaches should become familiar with the signs and symptoms of concussion that are described in section I.
      • Very basic cognitive testing should be performed to determine cognitive deficits.
        • See appendix E.
    • Remove from activity
      • If a coach suspects the athlete has sustained a concussion, the athlete should be removed from activity until evaluated medically.
        • Any athlete who exhibits signs or symptoms of a concussion should be removed immediately, assessed, and should not be allowed to return to activity that day.
    • Refer the athlete for medical evaluation
      • Coaches should report all head injuries to the GISH Certified Athletic Trainer (AT), as soon as possible, for medical assessment and management, and for coordination of home instructions and follow-up care.
        • The AT can be reached at: 308-380-9566.
        • The AT will be responsible for contacting the athlete's parents and providing follow-up instructions.
      • Coaches should seek assistance from the host site AT if at an away contest.
      • If the GISH AT is unavailable, or the athlete is injured at an away event, the coach is responsible for notifying the athlete's parents of the injury.
        • Contact the parents to inform them of the injury and make arrangements for them to pick the athlete up at school.
        • Contact the AT at the above number, with the athlete's name and home phone number, so that follow-up can be initiated. Additional copies are available from the AT.
        • Remind the athlete to report directly to the school nurse before school starts, on the day he or she returns to school after the injury.
      • In the event that an athlete's parents cannot be reached, and the athlete is able to be sent home (rather than directly to MD):
        • The Coach or AT should insure that the athlete will be with a responsible individual, who is capable of monitoring the athlete and understanding the home care instructions, before allowing the athlete to go home.
        • The Coach or AT should continue efforts to reach the parent.
        • If there is any question about the status of the athlete, or if the athlete is not able to be monitored appropriately, the athlete should be referred to the emergency department for evaluation. A coach or AT should accompany the athlete and remain with the athlete until the parents arrive.
        • Athletes with suspected head injuries should not be permitted to drive home.

VI. FOLLOW-UP CARE OF THE ATHLETE DURING THE SCHOOL DAY

  •  Responsibilities of the school nurse after notification of student's concussion
    • The athlete will be instructed to report to the school nurse upon his or her return to school. At that point, the school nurse will:
      • re-evaluate the athlete utilizing a graded symptom checklist.
      • provide an individualized health care plan based on both the athlete's current condition, and initial injury information provided by the AT or parent.
    • Notify the student's guidance counselor and teachers of the injury immediately via the individualized health care plan form.
    • Notify the student's P.E. teacher immediately that the athlete is restricted from all physical activity until further notice.
    • If the school RN receives notification of a student-athlete who has sustained a concussion from someone other than the AT (athlete's parent, athlete, physician note), the AT should be notified as soon as possible, so that an appointment for ImPACT testing can be made.
    • Monitor the athlete on a regular basis during the school day.
  • Responsibilities of the student's guidance counselor or principal
    • Monitor the student closely and recommend appropriate academic accommodations for students who are exhibiting symptoms of post-concussion syndrome.
    • Communicate with school health office on a regular basis, to provide the most effective care for the student.

VII. RETURN TO PLAY (RTP) PROCEDURES AFTER CONCUSSION

  • Returning to participate on the same day of injury
    • As previously discussed in this document, an athlete who exhibits signs or symptoms of concussion, or has abnormal cognitive testing, should not be permitted to return to play on the day of the injury. Any athlete who denies symptoms but has abnormal sideline cognitive testing should be held out of activity.
    • "When in doubt, hold them out."
  • B. Return to play after concussion
    • The athlete must meet all of the following criteria in order to progress to activity:
      • Asymptomatic at rest and with exertion (including mental exertion in school) AND:
      • Within normal range of baseline on post-concussion ImPACT testing AND:
      • Have written clearance from physician trained in ImPACT Testing (athlete must be cleared for progression to activity by ImPACT trained physician other than an Emergency Room physician).
      • Have Return to Play Parental/Guardian Release Form signed.
    • Once the above criteria are met, the athlete will be progressed back to full activity following a stepwise process, (as recommended by both the Prague and NATA Statements), under the supervision of the AT.
    • Progression is individualized, and will be determined on a case by case basis. Factors that may affect the rate of progression include: previous history of concussion, duration and type of symptoms, age of the athlete, and sport/activity in which the athlete participates. An athlete with a prior history of concussion, one who has had an extended duration of symptoms, or one who is participating in a collision or contact sport should be progressed more slowly.
    • Stepwise progression as described in the Prague Statement:
      • No activity – do not progress to step 2 until asymptomatic
      • Light aerobic exercise – walking, stationary bike
      • Sport-specific training (e.g., skating in hockey, running in soccer)
      • Non-contact training drills
      • Full-contact training after medical clearance
      • Game play
      • Note: If the athlete experiences post-concussion symptoms during any phase, the athlete should drop back to the previous asymptomatic level and resume the progression after 24 hours.
    • 5. The AT and athlete will discuss appropriate activities for the day. The athlete will be given verbal and written instructions regarding permitted activities. The AT and athlete will each sign these instructions. One copy of this form is for the athlete to give to the coach, and one will be maintained by the AT.
    • 6. The athlete should see the AT daily for re-assessment and instructions until he, or she, has progressed to unrestricted activity, and been given a written report to that effect, from the AT.

 

[i] McCrory P, et al. Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sports Med. 2005; 15(2):48-55.

[ii] Guskiewicz KM, et al. National Athletic Trainers' Association Position Statement: Management of Sport- Related Concussion. J Athl Train. 2004;39(3):280-297.

[iii] Guskiewicz KM, et al