Background:
MSJ Sports Medicine is committed to providing the best care possible for student-athletes who have sustained a concussion.  Recognizing that a concussion effects not only athletics participation, but also a student’s ability to attend classes, the healthcare team seeks to provide a thorough framework for return to play and return to the classroom.  To that end, it is important to define concussion and clearly state the policies and objectives of care for the concussed student-athlete.  The “Zurich Guidelines” that came out of the 4^th International Conference on Concussion in Sport defines concussion in this way:

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1) Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an ‘‘impulsive’ force transmitted to the head. 2) Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours. 3) Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies. 4) Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

The table below shows the most common signs and symptoms associated with concussion.  It is important to note that a student-athlete may exhibit some or all of these signs/symptoms at any point during initial injury and subsequent treatment.

Signs and Symptoms of Concussion
Physical Headache Nausea Vomiting Balance Problems Fatigue Sensitivity to Light Numbness/Tingling Dazed Stunned	Cognitive Feeling mentally foggy Feeling slowed down Difficulty concentrating Difficulty remembering Forgetful of recent information and conversations Confused about recent events Answers questions slowly	Emotional Irritable Sad More emotional Nervous Sleep Drowsiness Sleeping more than usual Sleeping less than usual Difficulty falling asleep

 
The majority of concussions will resolve in a relatively short time (7-10) days though recovery time can vary dependent on certain other factors such as severity of injury, past history of brain injury, and initial management.  Persistent, long-term symptoms occur in 10-15% of concussions.  The documented potential health risks associated with returning to play before symptoms have subsided support the possibility of increased post concussive vulnerability.  A second blow to the head before complete healing may result in prolonged recovery time and increased or worsening symptoms.  Furthermore, studies have suggested that early cognitive or physical activity prolongs recovery and can lead to dysfunctions such as decreased reaction time and decreased cognitive ability.

Mount St. Joseph University Concussion Policy

MSJ Sports Medicine resolves to provide high quality education, assessment, and management of concussions in order to assure that MSJ student-athletes who sustain a concussion receive the best possible care.  The comprehensive recommendations in this policy represent the best practices in current literature. 

Education

Coaches and athletes are not always aware of the symptoms and seriousness of concussions.  Frequently, coaches are not trained to identify a concussion and may miss serious symptoms while under pressure to perform their coaching duties.  The purpose of pre-season education is to give coaches and student-athletes the necessary tools to recognize the signs and symptoms of a concussion so they can implement the management plan as soon as possible and avoid potentially more serious injuries.

1.  Student-athlete education occurs during the annual pre-participation physicals.  Each student-athlete will receive a copy (electronic or hard copy) of the NCAA Concussion Fact Sheet for Student-Athletes.  As the year progresses athletic trainers will attend team meetings to review the signs and symptoms of concussion.  The athletic trainer will also review this policy, outline the risks associated with non-compliance of reporting head injuries, and make sure the team has contact information for relevant sports medicine staff.

 
Each student-athlete will sign a copy of the Student-Athlete Concussion Statement which acknowledges:

1. Student-athlete has received, read, and understands the NCAA Concussion Fact Sheet for Student-Athletes.
2. Student-athlete accepts the responsibility of immediately reporting their injuries and illnesses to a MSJU Healthcare Team member.

The signed document will become part of the student-athlete’s medical record maintained by the team’s athletic trainer.
 

2. Coach education will occur as part of the pre-participation physicals or during pre-season meetings.  The head coach and all assistants will receive a copy (electronic or hard copy) of the NCAA Concussion Fact Sheet for Coaches.  An electronic copy of the MSJU Concussion Policy and Management Plan will made available on the MSJ Sports Medicine website (MSJ Concussion Policy)

Each coach will sign the Coach’s Concussion Statement which acknowledges:

1. Coach has read and understood the NCAA Concussion Fact Sheet for Coaches.
2. They will encourage student-athletes to report injuries to medical staff
3. Coach accepts responsibility for referring student-athletes with suspected concussions to medical staff
4. They are educated regarding safe play and proper technique. 
5. The coach recognizes that the MSJU Healthcare Team has autonomous authority in return to play decisions.
6. Coach has read and understood the MSJU Concussion Policy and Management Plan

These signed documents will be delivered to the Head Athletic Trainer.  It is the Head Athletic Trainer’s duty to keep the documents on file for the entire academic year.

3. The University Health and Wellness Department staff will receive a copy of the NCAA Concussion Fact Sheet for Coaches and a hard copy of the MSJU Concussion Policy and Management Plan. 

 

4. The Athletic Director will receive a copy (electronic or hard copy) of the NCAA Concussion Fact Sheet for Coaches and the MSJU Concussion Policy and Management Plan.

 

5. All MSJU athletic trainers and team physicians will be trained annually on the MSJU Concussion Policy and Management Plan.  Each athletic trainer and team physician is expected to read, understand, and follow the protocol to ensure the delivery of quality health care to all student-athletes.

 
Pre-Participation Assessment
All MSJ student-athletes will complete baseline testing as part of the pre-participation exam prior to clearance for participation in any MSJ sponsored athletic activity.  In compliance with the NCAA Arrington Settlement, each student-athlete will have baseline testing for every sport that they participate. When a student-athlete sustains a concussion, new baseline testing will be completed during the next year’s pre-participation exam or earlier depending on medical advice. 

Recognition and Diagnosis of Concussion

On Field/Sideline Evaluation
MSJ Sports Medicine will hold to the recommendations set forth by the 4^th International Conference on Concussion in Sport.  In any instance where a student-athlete is suspected of having a concussion or symptoms of concussion are present he or she will be evaluated by an athletic trainer and/or a physician.  During the evaluation the provider will also take care to assess for comorbidities including skull fracture, cervical spine trauma, and intracranial bleeding.

It is vitally important that the student-athlete be assessed in a timely manner.  If no athletic trainer or physician is available coaches should take steps to ensure the student-athlete is safely removed from play.  Referral to an appropriate healthcare provider for evaluation should be conducted as urgently as possible.

When it is clear that no other injury exists for which an emergency referral is necessary, an immediate assessment of the concussion will be made using SCAT5 or other comparable testing platform.
Serial monitoring is essential.  Concussion has been shown to be an evolving injury.  The student-athlete should be periodically reevaluated for emerging or worsening symptoms.  If any concussive symptoms are found or a part of the testing is failed the student-athlete will be removed from play and the Concussion Management Plan is activated. A student-athlete with a diagnosed concussion will not be allowed to return to play on the day of injury.

If the student-athlete does not show signs of concussion, fails any test, or denies symptoms of concussion he or she will be given a series of progressive exertional tests in consideration for return to play.  The progression will go as follows: general aerobic activities > intense bouts of aerobic activity > sport specific activities.  If symptoms are reported or noted during any point of the progression the student-athlete is diagnosed with a concussion and removed from play; the Concussion Management Plan is activated.  If no symptoms are reported during the exertional testing the student-athlete may return to play.  It is recommended that a medical professional monitors and evaluates the student-athlete throughout the remainder of the activity.  If symptoms of concussion are present at any time the student-athlete will be removed from play.
 
Mount St. Joseph University Concussion Management Plan
Post-Concussion Management
A student athletic with a suspected concussion is not permitted to return to play on the same day as injury or at any time while symptomatic.  If an athletic trainer or other medical professional is not present when a concussion occurs a coach must inform the team athletic trainer of the injury.  The athletic trainer will then coordinate follow-up care and in-office evaluation.

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• After the initial on-field assessment, the athletic trainer or physician will conduct further evaluation in office or clinic if necessary.  This evaluation will include a full SCAT5, including SAC test, or other testing platform as available if testing was difficult to complete or incomplete.
• The athletic trainer will notify the team physician and coordinate follow up care.  Follow up assessment and care should take place within 24 hours.
• Follow up care consists of the student athlete completing CVS symptoms scale every one to two days to monitor symptom resolution.
• Student athletes should be seen by the team physician as soon as possible, preferably during the next scheduled office hours on Mondays or Thursdays, or at an on campus sporting event.
• Team physicians may request repeat SAC test if the student athlete performed poorly on the initial test.  Repeat test can be done by the team physician or athletic trainer depending upon workload.
• A student-athlete with a concussion should not attend classes, clinical assignments, or other academic responsibilities for at least the same day as the concussion occurred, preferably until after being evaluated by the team physician.

Return to Learn Plan

• During the initial recovery period immediately following the injury the student-athlete should adhere to relative cognitive and physical rest.  No in class work or homework should be completed on day of injury.  Unless directed otherwise the student-athlete may participate in low-level mental activity such as watching tv, texting or talking on the phone as long as symptoms are not exacerbated by such activity.  These activities should be kept to a minimum, however, since they can prolong recovery.
• When a student-athlete begins to improve and concussion symptoms do not return with mental activity the Return to Learn Plan can be implemented.  The plan is a gradual return to full cognitive workload and will be managed by the Director of Learning Center and Disability Services.
• The plan will be tailored specifically to address each student-athletes’ needs.
• MSJ team physicians will dictate the return to learn guidelines on an individual basis and document limitations on designated return to learn form for disability services.
• Upon discussion of the limitations, the student athlete will sign the individualized form to allow for disability services to share the information with the necessary faculty members. This will also signify student athlete comprehension of the prescribed limitations.
• The certified Athletic Trainer covering physician hours will scan completed form and email a copy to Heather Crabbe in disability services (Heather.Crabbe@msj.edu ), the student athlete, and cc Natalie Bechtol (Natalie.Bechtol@msj.edu) in the Wellness Center.
• The paper copy of the return to learn form will be kept in the student athlete’s personal medical file.
• This form will be updated based upon injury progression until the student athlete is asymptomatic or is cleared by the team physicians to start the return to play rehabilitation.

 

Return to Learn Plan

Gradual reintroduction of cognitive activity; 5-15 minute increments; limited hours per day Homework at home; 20-30 minute increments; limited hours per day School re-entry; partial day and homework; frequent rest periods; Full day of school; rest periods available if symptoms return Resumption of full cognitive workload

 
 
 
Return to Play Protocol
When the student-athlete becomes asymptomatic for a 24-hour period and the SCAT5 or other post- concussion testing score is at baseline, the team physician will give clearance to begin the return to play protocol.  At MSJ the team physician will communicate at several key points throughout the process and authorizes the team athletic trainer to complete the testing, symptom monitoring, and readiness for advancing to the next step.  The student-athlete must complete the CVS cognitive test and be evaluated by a team physician prior to  advancing to stage 4: practice or competition.  This protocol is a graduated return to physical activity.

• SCAT5 or other testing as available administered and score determined to be back to baseline or at least 95% of baseline.
• A symptom score is recorded before and after each step. 
• No more than one (1) step can be completed on the same day and should be separated by at least twelve (12) hours. 
• During progression, if the student-athlete experiences any concussion symptoms during the exertional testing the progression will be stopped.  The student-athlete is then referred to a physician.  An evaluation and symptom assessment will be conducted daily until the student-athlete is asymptomatic. Daily symptom monitoring is handled by the athletic trainer
• The protocol will then be restarted at the highest level achieved without symptoms.
• The final determination regarding concussion diagnosis and/or fitness to return to play is a medical decision based on clinical judgement and no steps will be skipped in an effort to accommodate practice or game schedules for any reason.
• A student-athlete will cleared by a physician before being cleared for practice or competition
• When a student-athlete is clear to return to play and is ready for full participation, a form called Concussion Return to Play Acknowledgment is given to the student-athlete.  This document seeks to educate the student-athlete on concussion signs/symptoms.  Student-athletes will state that they are free of these signs and symptoms at the time of clearance, that a gradual return to play has been managed, and that any returning signs/symptoms will be reported immediately to healthcare personnel.

Return to Play Protocol Steps

Step 1: Light aerobic exercise:  Stationary bike ride (10-14 mph) for 20 minutes

Step 2:  Moderate aerobic exercise/interval exercise/resistance training: Stationary bike ride intervals 30 sec sprint (18-20 mph)/30 sec recovery (10-14 mph) x 10 Body weight resistance squats/push-ups/burpees x 20reps x 3

Step 3: Intense aerobic exercise/sport specific activities: 60 yd shuttle run x 10 (40 sec rest) Plyometric workout – 10 yd bounding, 10 med ball throws, 10 vertical jumps x3 Non-contact sport-specific drills for ~15 mins Physician assessment/evaluation before moving to Step 4

Step 4: Limited/controlled return to practice: Non-contact May participate in all practice activity that is not against an opponent or that has the potential for head contact

Step 5: Full practice: Contact

Step 6: Return to competition

 

5. No student-athlete may return to full activity or competition until asymptomatic in limited, controlled, and full contact activities AND cleared by team physician or athletic trainer. 

Prolonged Recovery and Medical Disqualification
A student-athlete with a prolonged recovery or history of multiple concussions will be evaluated by a physician to consider additional diagnosis and further treatment options.  Referrals to address complications will coordinated by the MSJU Healthcare Team.
Medical Disqualification of a student-athlete will be determined on a case by case basis.  Cognitive changes that affect activities of daily living, increasing symptom scores, prolonged recovery, history of multiple concussions with complications, or concussions occurring more easily will all be factors discussed when considering a medical disqualification.  The MSJU Healthcare Team strives to make these decisions based on comprehensive medical advice, interviews with relevant persons, and current practice standards.

Reducing Exposure to Head Trauma
The NCAA Arrington Settlement states: “NCAA member institutions shall ensure that medical personnel with training in the diagnosis, treatment and management of concussion are present at all Contact Sports games for Divisions I, II and III.”

 At MSJ, a certified athletic trainer licensed by the state of OH OPPTAT Board will be available for all contact sports games, home or away.  Contact sports offered at MSJ: football, men/women lacrosse, wrestling, men/women soccer, and men/women basketball.

In addition, the NCAA Arrington Settlement states:  “NCAA member institutions shall ensure that medical personnel with training in the diagnosis, treatment and management of concussion are available at all Contact Sports practices for Divisions I, II and III.” 

At MSJ, a certified athletic trainer licensed by the state of Ohio OPPTAT Board will be available for all contact sports practices.  Contact sports offered at MSJ: football, men/women lacrosse, wrestling, men/women soccer, and men/women basketball.

The NCAA provides some bylaws and general guidelines which restrict contact at football practices, but does not specifically address the issue for other sports.  For football, the MSJU Healthcare Team recommends adherence to the
Inter-Association Consensus: Year-Round Football Practice Guidelines (http://www.ncaa.org/health-and-safety/football-practice-guidelines).  It is essential for coaches and athletic trainers to be familiar with this document and implement the recommendations.  The coaching staff at Mount St. Joseph University is encouraged to follow NCAA guidelines, to teach proper technique, and to promote an attitude of safe play when approaching their respective sports.