Defining the nature of a concussive head injury includes:
Pediatric concussion management
Panel agreed that evaluation and management recommendations be applied to children and adolescents down to the age of 10 years and these children should not be returned to practice or play until clinically completely symptom free which may require longer time frame than for adults. Emphasis was placed on “cognitive rest” where school attendance and activities may need to be modified to avoid provocation of symptoms. The child also needs to limit exertion with activities of daily living and to limit scholastic and cognitive stressors (e.g. text messaging, videogames, etc) while symptomatic.
The consensus panel agreed that a range of “modifying” factors may influence assessment and management of concussions restricting child longer. These factors are:
Signs and Symptoms of a concussion:
v Dazed appearance
v Confused about assignment, forgets plays
v Unsure of game, score or opponent
v Moves clumsily
v Answers questions slowly
v Loses consciousness
v Shows behavior or personality changes
v Can’t recall events prior to hit or after hit
v Headache, nausea, dizziness
v Balances problems
v Double or fuzzy vision
v Sensitivity to light or noise
v Feeling sluggish, foggy, or groggy
v Concentration or memory problems
When a player shows ANY symptoms or signs of a concussion:
5. A head injury-warning sheet must be given to the athlete, parent/guardian, or friend of the athlete who is taking care of them.
A player should never return to play while symptomatic.
“WHEN IN DOUBT, SIT THEM OUT!
Return to play PROTOCOL
Once a student diagnosed with a concussion has been symptom free at rest for at least 24 hours, a private medical provider may choose to clear the student to begin a graduated return to activities. If a district has concerns or questions about the private medical provider’s orders, the district medical director should contact that provider to discuss and clarify. Additionally, the medical director has the final authority to clear students to participate in or return to extra-class physical activities in accordance with 8NYCRR 135.4(c)(7)(i).
Students should be monitored by district staff daily following each progressive challenge, physical or cognitive, for any return of signs and symptoms of concussion. Staff members should report any observed return of signs and symptoms to the school nurse, certified athletic trainer, or administration in accordance with district policy. A student should only move to the next level of activity if they remain symptom free at the current level. Return to activity should occur with the introduction of one new activity each 24 hours. If any post concussion symptoms return, the student should drop back to the previous level of activity, then re-attempt the new activity after another 24 hours have passed. A more gradual progression should be considered based on individual circumstances and a private medical provider’s or other specialist’s orders and recommendations.
Phase 1- low impact, non-strenuous, light aerobic activity such as walking or riding a stationary bike. If tolerated without return of symptoms over a 24 hour period proceed to;
Phase 2- higher impact, higher exertion, and moderate aerobic activity such as running or jumping rope. No resistance training. If tolerated without return of symptoms over a 24 hour period proceed to;
Phase 3- Sport specific non-contact activity. Low resistance weight training with a spotter. If tolerated without return of symptoms over a 24 hour period proceed to;
Phase 4- Sport specific activity, non-contact drills. Higher resistance weight training with a spotter. If tolerated without return of symptoms over a 24 hour period proceed to;
Phase 5- Full contact training drills and intense aerobic activity. If tolerated without return of symptoms over a 24 hour period proceed to;
Phase 6- Return to full activities without restrictions.
With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. If any post concussion symptoms occur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours.
An additional consideration in return to play is that concussed athletes should not only be symptom free but also should not be taking any pharmacological agents/medications that may effect or modify the symptoms of concussion.
The above policy will be followed by the healthcare professionals (school physician, school nurses, athletic trainer, athletic department) that deal with the return to play of student athletes at local high schools and colleges that are under contract for athletic training services with AthletiCare. This concussion management/return to play protocol will be followed despite the athlete presenting a prescription note to return to play sooner from their primary care physician or Emergency room. If an athlete presents a prescription from their primary care physician for the appropriate time frame in regards to return to play, then the exertional progressive steps will be followed by the athletic trainer using the return to play protocol Impact Concussion Testing Managment System.
Please have the appropriate professionals sign off on this policy and make copies for the athletic office, nurse’s/MD office, and athletic training room at your school. If you do not have the professionals below or more than the lines provided at your school district, please leave those blank or add them to the below section to sign off on.