Concussion and Head Injury Protocol

Policy, Assessment, Management, and Return to Play Guidelines

Revised – May 18, 2015

The following document summarizes those policies, procedures and return-to-play guidelines related to the management of concussions and other head injuries for NCAA Division III student-athletes at Willamette University. The information has been developed in accordance with the Willamette University Athletic Department Mission Statement to provide quality services and assure the well-being of each student-athlete

I. PURPOSE

The department of athletics at Willamette University recognizes that concussions and other head injuries pose a significant health risk for those students participating in sports. The sports medicine staff has implemented policies and procedures to assess and identify those student-athletes who have suffered a concussion. The sports medicine staff also recognizes that baseline neurocognitive testing on student-athletes will provide significant data for return to competition decisions for those who participate in “high risk” sports (as identified by the NCAA) and/or those who have had a history of concussions prior to entering Willamette University. This baseline data, along with physical examination, and/or further diagnostic testing, will be used together to determine when it is safe for a student-athlete to return to competition.

II. GUIDING PRINCIPLES

  • Athletes who are observed, or who have otherwise reported concussion symptoms, including loss of consciousness or memory, dizziness, headache, nausea or confusion, will be assessed and treated through this Willamette University Sports Medicine Concussion Management Plan. Any athlete exhibiting signs and symptoms of a concussion shall not return to physical activity on the same day of the injury.
  • Athletes who are suspected to have sustained a concussion will be examined as soon as possible by a certified athletic trainer using the Willamette University Athletic Training concussion assessment instrument. Management will be decided by the athletic trainer and physician (if present) based on the initial assessment and any previous history of concussion.
  • Athletes who have sustained a concussion are referred to the Willamette University Office of Disability Services for academic accommodations as defined by the Disability Services Concussion Protocol.
  • Athletes who present with an altered state of consciousness and are unable to communicate with the athletic trainer or physician will be referred immediately for evaluation of cervical spine and/or intracranial pathology.

III. MANAGEMENT PROTOCOL

  • The Willamette University Concussion Management Plan is to be administered by the Willamette certified athletic training staff under the direction of the team physician(s). The plan is to be regularly reviewed by the team physician(s), certified athletic training staff, Director of Bishop Wellness Center, and other university staff, as appropriate.
  • Proposed revisions to Willamette University Concussion Management Plan will be forwarded by the head athletic trainer to the Director of Athletics, Dean of Campus Life, university legal counsel, and risk management and insurance administrators for approval. Students, coaches, and sports medicine staff will be provided updated concussion plan information upon approval.
  • All student-athletes, coaches and athletic training staff will receive annual training about the risks, reporting, and management of concussions and other head injuries.
  • Athletic coaches are prohibited from serving as the primary supervisor for Willamette athletics health care providers (athletic trainers, team physicians). In the event that the supervisor has additional coaching responsibilities, management for athletics health care providers will be reassigned to a new supervisor, to be approved by the Dean of Campus Life, Director of Human Resources, and/or President.
  • Willamette athletics health care providers (athletic trainers, team physicians) have the final authority to remove any such athlete with a concussion or other suspected head injury from practice, training or competition. In the event a Willamette athletics health care provider is not present, management will be the responsibility of the host athletics health care provider (in an away event) or head coach. Coaches are urged to immediately refer the student-athlete to a certified athletic trainer or nearest emergency room dependent on the circumstances.
  • Willamette athletics health care providers (athletic trainers, team physicians) have the final authority to prevent the return to training, practice or competition of any such athlete with a concussion or other suspected head injury.
  • Willamette athletics health care providers have the final authority to immediately refer any such athlete with a concussion or other suspected head injury to an appropriately-qualified physician.
  • Final medical clearance (in order to return to all athletic activities) following concussion or another head injury will be made by the Willamette University team physician or designated staff certified athletic trainer. Other appropriate health care professionals, including the Bishop Wellness Center and/or neuropsychology professionals, may also be consulted.

IV. BASELINE ASSESSMENT

All student-athletes participating in their first season in sports which have been identified by the NCAA and/or who have had a previous history of concussion as identified by their health history will have a baseline neurocognitive test completed via the ImPACT neurocognitive screening tool as part of their athletic medical screening. The identified athletes will also establish a baseline score using the Balance Error Scoring System (BESS) Test.

It is important to remember that tests used by Willamette University Sports Medicine:

  • are screening devices only, they are not intended for determination or diagnosis
  • will be used as one of several factors to make decisions regarding return to play and safety of student-athlete
  • regardless of test results, player may be removed from practice or play until such time as the individual can have a neurological or neuropsychological examination to determine extent of injury, if any
  • Willamette team physician or designee will have unchallengeable authority to determine management and return-to-play

The following Willamette teams/athletes currently undergo neurocognitive baseline testing: Football, Men’s Soccer, Women’s Soccer, Men’s Basketball, Women’s Basketball, Baseball, Softball, Pole Vaulters/Decathletes

V. CONCUSSION DEFINITION

Definition of Concussion: a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.(1)

In accordance with NCAA guidelines, all student-athletes will be required to sign a statement in which they accept the responsibility for reporting their illnesses and injuries to the university medical staff, including signs and symptoms of a concussion. During the review and signing process the student-athletes will be presented with educational material on concussions.

VI. CONCUSSION SIGNS AND SYMPTOMS

A unanimous agreement reached at the 3rd International Conference on Concussion in Sport in 2008 was that grading of concussion and even the Simple vs. Complex terminology previously proposed should be abandoned. The panel did agree that the majority (80-90%) of concussions resolve in a short (7-10 day) period, with the exception of longer time frames in children and adolescents. The diagnosis of concussion involves the assessment of a range of domains, and can include one or more of the following:

  1. Symptoms: somatic (eg, headache), cognitive (eg, felling like in a fog) and/or emotional symptoms (eg,sadness)
  2. Physical signs (eg, LOC, amnesia)
  3. Behavioral changes (eg, irritability)
  4. Cognitive impairment (eg, slowed reaction time)
  5. Sleep disturbance (eg, drowsiness)

If any one or more of these components is present, a concussion should be suspected and the following management strategy instituted.

Certified athletic trainers and athletic training students all need to be aware of the signs and symptoms of concussion to properly recognize and intervene on behalf of the student-athlete.

VII. CONCUSSION MANAGEMENT

It is imperative that concussion management include both physical and cognitive rest, otherwise the athlete is at the risk of exacerbating symptoms and prolonging recovery or even causing permanent injury. The majority of injuries will recover spontaneously over several days and it is expected that an athlete will proceed progressively through a stepwise return to play strategy. No unnecessary physical activity should be allowed and the following guidelines for academic participation are suggested:

  1. Disability Services, in collaboration with the student-athlete and the supervising certified athletic trainer, shall communicate to the student-athlete’s professors that attending class while suffering from concussion symptoms is likely to be detrimental not only to their recovery but also to their academic performance.
  2. Mental rest will be recommended for each concussed student-athlete. This may include missing classes, deferring reading assignments and homework, and rescheduling tests. The team-physician will make recommendations on an individual basis for student-athletes that need to miss academic work.
  3. When returning to class, the student-athlete should work with disability services on obtaining class notes. They are encouraged to consult with professors about any and all available class materials.
  4. Use of computers or watching a TV should be limited to brief time periods that don’t increase symptoms.

All unnecessary stimulation, including light and sound should be minimized or eliminated if possible during the recovery period.

Neuropsychological Assessment

Once the athlete is symptom free they will take the ImPACT test to determine if they have returned to baseline or normal cognitive function. Both physical and cognitive symptoms must have returned to near baseline before the gradual return to play protocol is initiated. Further consultation with neurological professionals, including neurophysiologist, will be at the discretion of the team physician

VIII. WILLAMETTE UNIVERSITY CONCUSSION ASSESSMENT

On-field and Sideline Assessment of Acute Concussion

When an athlete shows ANY features of a concussion:

  1. The athlete should be immediately evaluated onsite using standard emergency procedures with particular attention given to excluding a cervical spine injury.
  2. If an appropriate healthcare provider is not present, the athlete should be safely removed from activity and urgent summons of a certified athletic trainer or referral to a medical facility made.
  3. Once emergency management issues are addressed, a concussion assessment should be made using the attached instrument or similar tool.
  4. The athlete should not be left alone following the injury, written instructions and serial monitoring for deterioration should be made over the subsequent few hours following injury.
  5. A player diagnosed with a concussion will not be allowed to return to play on the day of the injury

IX. RETURN TO PLAY PROTOCOL

A stepwise return to play protocol is outlined below.

The athlete may proceed to the next level if asymptomatic at the current level and scores near baseline or near normal on ImPACT testing.

Signs & symptoms, balance and neurocognitive testing in conjunction with the team physician consultation and additional diagnostic tests (as needed) shall determine when a student-athlete will return to full practice/competition.

Continued post-concussive symptoms, prior concussion history and any diagnostic testing results along with neurocognitve testing and physical exam, will be utilized by the sports medicine team in establishing a timeline for an athletes return to activity.

It is important to note that this timeline could last over a period of days to weeks or months, or potential medical disqualification from Willamette University athletics. All cases will be handled on a case-by-case basis.

The decision by the team physician or designee for all cases of an athletes return to activity is final.

Functional Protocol

The functional protocol should not be initiated until:

  • Athlete is symptom free 24 hours after the concussive episode

A 24-hour period between steps is the minimum time frame.

If any post-concussion symptoms occur while in the stepwise program, the athlete will drop back to the previous asymptomatic level and progress again after a new 24-hour period of rest.

Day 1

Athlete has been symptom free for 24 hours

Day 2

  • At this point student-athlete must have remained asymptomatic to progress in protocol
  • Tour de Bearcat (page 11) on a stationary bicycle.
  • 10 minutes of continuous jogging.
  • 5 sprints of 30 yards.
  • Agility drills (varies sport to sport).

Prior to moving on to Day 3

  • Student-athlete must take ImPACT and BESS follow-up test
  • Test results must return to acceptable pre-seasons baseline scores

Day 3

  • Non-contact practice.

Day 4

  • May return to full activity.

After each phase of functional testing, the presence of post-concussive symptoms should be assessed and progression to the next phase of functional testing will require the absence of post-concussive symptoms. The athlete may not return to full activity until 4 days after normalization.

X. MODIFYING FACTORS:

Several modifying factors exist that may influence the management of concussion and even predict the potential for prolonged or persistent symptoms. In these cases, there may be additional management considerations beyond the return to play protocol above. The items in the list below are common concussion modifiers, but are not the only ones.

  1. number, duration (>10 days), and severity of symptoms
  2. prolonged LOC (>1 minute) or amnesia
  3. convulsions
  4. repeated concussions over time, injuries close together in time, “recency” of previous concussion
  5. repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion
  6. age under 18 y/o
  7. migraine, depression or other mental health disorders, ADHD, LD, and sleep disorders
  8. psychoactive drugs or anticoagulants
  9. dangerous style of play
  10. high-risk activity, contact and collision sport, and/or high sporting level

Along with the above guidelines, each case is treated on an individual basis to determine the safest return to activity as possible.