Section 2: Concussion Education Plan

Most students with a concussion recover quickly and fully. But for some students, symptoms can last for days, weeks, or longer. In general, recovery may be slower among older adults, young children, and teens. Those who have had a concussion in the past are also at risk of having another one and may find that it takes longer to recover if they have another concussion (CDC, Injury Prevention & Control: Traumatic Brain Injury).

A concussion education plan must address the following provisions from Public Act No. 14-66:An Act Concerning Youth Athletics and Concussions:

• For the school year commencing July 1, 2015, and each school year thereafter, each local and regional board of education shall prohibit a student athlete from participating in any intramural or interscholastic athletic activity unless the student athlete, and a parent or guardian of such student athlete, (1) reads written materials, (2) views online training or videos, or (3) attends in-person training regarding the concussion education plan.
• For the school year commencing July 1, 2015, and each school year thereafter, each school shall provide each participating student athlete’s parent or legal guardian with a copy of the informed consent form developed or approved by the State Board of Education. Such informed consent form shall include, at a minimum, (A) a summary of the concussion education plan, and (B) a summary of the applicable local or regional board of education’s policies regarding concussions. Each school must obtain the parent or legal guardian’s signature, attesting to the fact that such parent or legal guardian has received a copy of such form and authorizes the student athlete to participate in the athletic activity.
• The coach of any intramural or interscholastic athletics shall immediately remove a student athlete from participating in any intramural or interscholastic athletic activity who (A) is observed to exhibit signs, symptoms or behaviors consistent with a concussion following an observed or suspected blow to the head or body, or (B) is diagnosed with a concussion, regardless of when such concussion may have occurred. Upon such removal, a qualified school employee, as defined in subsection (e) of section 10-212a of the Connecticut General Statutes, shall notify the student athlete’s parent or legal guardian that the student athlete has exhibited such signs, symptoms, or behaviors consistent with a concussion or has been diagnosed with a concussion. Such qualified school employee shall provide such notification not later than 24 hours after such removal and shall make a reasonable effort to provide such notification immediately after such removal.
• The coach shall not permit such student athlete to participate in any supervised team activities involving physical exertion, including, but not limited to, practices, games or competitions, until such student athlete receives written clearance to participate in such supervised team activities involving physical exertion from a licensed health care professional trained in the evaluation and management of concussions.
• Following clearance outlined above, the coach shall not permit such student athlete to participate in any full, unrestricted supervised team activities without limitations on contact or physical exertion, including, but not limited to, practices, games, or competitions, until such student athlete (A) no longer exhibits signs, symptoms or behaviors consistent with a concussion at rest or with exertion, and (B) receives written clearance to participate in such full, unrestricted supervised team activities from a licensed health care professional trained in the evaluation and management of concussions.

The Recognition of Signs or Symptoms of a Concussion

There are stereotypical signs and symptoms associated with concussion. Directed questioning is necessary to obtain these details, as students (or their families) often do not think to offer information about these symptoms in open-ended questioning. Common symptoms in concussion are generally divided into physical/somatic, cognitive/thinking/remembering, sleep, and emotional/mood disruption categories. Attention to each individual symptom on the checklist provided in table 1 below is important while obtaining a clinical history of the student (Master and Grady 2012).

Table 1. Signs and Symptoms of Concussions

Physical	Sleep	Cognitive (Thinking/Remembering)	Mood Disruption
Headache	Sleeping more or less than usual	Difficulty thinking or concentrating	More emotional
Nausea	Drowsiness or fatigue	Difficulty remembering	Irritable
Vomiting	Trouble falling asleep	Confusion	Sad
Imbalane	Trouble maintaining sleep	Feeling mentally foggy	Nervous
Slowed reaction time		Feeling slowed down	Depressed
Dizziness		Decreased attention
Sensitivity to light		Decreased retention
Sensitivity to sound		Distractibility
Fuzzy or blurry vision		Amnesia

Source: adapted from Pardini et al., 2004.

Athletes who experience any of the signs and symptoms listed below after a bump, blow, or jolt to the head or body should be kept out of play the day of the injury and until a health care professional, experienced in evaluating concussions, provides written clearance that they are symptom-free and can return to play. It is important to note that some athletes may not experience and/or report symptoms until hours or days after the injury. Most people with a concussion will recover quickly and fully. For some people, however, signs and symptoms of a concussion can last for days, weeks, or longer.

Potential Signs Observed by Coaches, Athletic Trainers, Parents, or Others

• Appears dazed or stunned
• Is confused about assignment or position
• Forgets an instruction
• Is unsure of game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall

Potential Symptoms Reported by Athlete

• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish, hazy, foggy, or groggy
• Concentration or memory problems
• Confusion
• Does not “feel right” or is “feeling down” (CDC, How Can I Recognize a Possible Concussion?)

The Means of Obtaining Proper Medical Treatment for a Person Suspected of Sustaining a Concussion

Students with a suspected concussion should be seen by a health care professional. Coaches and athletic trainers are the supervising adults during intramural and interscholastic athletics and are therefore responsible for ensuring that students are removed from play and are provided with the appropriate medical attention. The coach shall not permit student athletes who are suspected of sustaining a concussion or who have been diagnosed with a concussion to participate in any supervised team activities involving physical exertion, including, but not limited to, practices, games or competitions, until such student athlete receives written clearance to participate in such supervised team activities involving physical exertion from a licensed health care professional trained in the evaluation and management of concussions.

After a concussion diagnosis, a comprehensive medical management plan should be implemented that follows the district’s concussion policy and includes communication among all those involved. This plan should include the family (such as, patient and parents), school personnel (such as, teachers, administrators, counselors, coaches), school medical personnel (such as, school nurses, athletic trainers and medical advisors), and community referral sources (such as, team physician, other health care referral sources). Communication among all these groups is essential for appropriate management of a concussed athlete (Journal of Athletic Training, 2014;49(2):255).

The following four-step action plan adapted from the CDC provides information on what should be done if a concussion occurs or is suspected.

1. Immediately remove the athlete from play. Look for signs and symptoms of a concussion if the athlete has experienced a bump or blow to the head or body. When in doubt, keep the athlete out of play.
2. Ensure that the athlete is evaluated by a health care professional. Do not try to judge the severity of the injury yourself. Health care professionals have a number of methods that they can use to assess the severity of concussions. Recording the following information can help them in assessing the athlete after the injury: 
   • cause of the injury and force of the hit or blow to the head or body;
   • any loss of consciousness (passed out/knocked out) and if so, for how long;
   • any memory loss immediately following the injury;
   • any seizures immediately following the injury; and
   • if known, the number of previous concussions.
3. Inform the athlete’s parents or guardians immediately or as soon as possible (required to occur within 24 hours in Connecticut) about the suspected concussion and that the athlete should be seen by a health care professional and that written clearance by a licensed health care professional trained in the evaluation and management of concussions must be provided to the school in order for the student athlete to participate in team activities involving physical exertion.
4. Keep the athlete out of play the day of the injury and until a licensed health care professional, experienced in evaluating for concussion, determines that the athlete is symptom-free and clears the student to begin the return-to-play protocol. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time (hours, days, or weeks)—can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in edema (brain swelling), permanent brain damage, and even death (CDC 2012).

Note: Best practice suggests that the athlete should be kept out of play until he or she has a normal exam, is back to his or her pre-injury academic participation and has completed a supervised graduated exercise (“Return-to-Play”) protocol (Br J Sports Med 2013;47: 250–258; Journal of Athletic Training 2014;49(2):245–265; Pediatric Annals Sept. 2012, 41 (9):1-6).

The Nature and Risks of Concussions, Including the Danger of Continuing to Engage in Athletic Activity after Sustaining a Concussion

The severity of a TBI or concussion may range from “mild,” (such as a brief change in mental status or consciousness), to “severe,” (such as an extended period of unconsciousness or amnesia after the injury). Concussions can cause a wide range of functional short- or long-term changes affecting thinking (i.e., memory and reasoning); sensation (i.e., touch, taste, and smell); language (i.e., communication, expression, and understanding); or emotions (i.e., depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age. About 75 percent of TBIs that occur each year are concussions or other forms of mild TBI. Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (such as, hours, days, or weeks) can be catastrophic or fatal.

To better understand the symptoms of concussion and the risk for long-term complications, the following adapted recommendations from the American Academy of Pediatrics (AAP) include that:

• All athletes with suspected concussions should not return to play until they see a doctor (or health care provider). Health care providers can confirm the diagnosis of concussion; determine the need for any specialized tests, such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), or neuropsychological tests; and determine when the athlete is ready to safely return to play.

Note: Following concussion, CTs and MRIs are almost invariably normal, and should not be used as the sole determination of return to play (Clin J Sports Med 2001:11:166).

• Athletes should rest their bodies and brains until they are no longer experiencing any symptoms of concussion. Physical and cognitive exertion, such as homework, playing video games, texting, using a computer, or watching TV may worsen symptoms.
• Symptoms of a concussion usually resolve in 7 to 10 days, but for some athletes, it may take weeks or months to fully recover.
• Neuropsychological testing can provide objective data to athletes and their families, but testing is just one step in the complete management of sport-related concussions.
• Retirement from contact or collision sports should be considered for an athlete who has sustained multiple concussions or who has suffered symptoms for longer than three months. Negative effects from concussions can accumulate from each event (AAP, Sports-Related Concussion: Understanding the Risks, Signs & Symptoms).

The Proper Procedures for Allowing a Student Athlete Who Has Sustained a Concussion to Return to Athletic Activity

When managing an athlete with a concussion, the management plan should cover both returning to school and to play, and should:

• include monitoring both physical and cognitive activities;
• consider concussion history; and
• be individualized to the athlete.

An athlete should be referred for follow-up care from a health care professional who can help him or her gradually return to school and to play when fully recovered. An athlete who has been diagnosed with a concussion should not return to practice or play the same day. In addition, Public Act No. 14-66: An Act Concerning Youth Athletics and Concussions requires that:

…coaches shall not permit such student athlete to participate in any supervised team activities involving physical exertion, including, but not limited to, practices, games or competitions, until such student athlete receives written clearance to participate in such supervised team activities involving physical exertion from a licensed health care professional trained in the evaluation and management of concussions. Following clearance, the coach shall not permit such student athlete to participate in any full, unrestricted supervised team activities without limitations on contact or physical exertion, including, but not limited to, practices, games or competitions, until such student athlete no longer exhibits signs, symptoms or behaviors consistent with a concussion at rest or with exertion, and receives written clearance to participate in such full, unrestricted supervised team activities from a licensed health care professional trained in the evaluation and management of concussions.

There are five gradual steps to help safely return an athlete to play, adapted from the International Concussion Consensus Guidelines.

Suggested Return-to-Play Progression

Step 1: Light Aerobic Exercise
Goal: only to increase an athlete's heart rate
Time: 5 to 10 minutes
Activities: exercise bike, walking, or light jogging. No weight lifting or resistance training, jumping, or hard running

Step 2: Moderate Exercise
Goal: limited body and head movement
Time: reduced from typical routine
Activities: moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting and resistance training. No head impact activities.

Step 3: Noncontact Exercise
Goal: more intense, but noncontact movement
Time: close to typical routine
Activities: running, high-intensity stationary biking, the player's regular weightlifting routine, and noncontact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Practice
Goal: reintegrate in full contact practice with vigilant observation by the coach and/or athletic trainer
Step 5: Return to Play
Goal: return to competition

It is important to monitor symptoms and cognitive function carefully during each increase of exertion. Athletes should only progress to the next level of exertion if they are not experiencing symptoms at the current level. If symptoms return at any step an athlete should stop these activities as this may be a sign that the athlete is pushing too hard. Only after additional rest, when the athlete is once again not experiencing symptoms for a minimum of 24 hours, should he or she start again at the step during which symptoms were experienced.

The Return-to-Play Progression process is best conducted through a team approach and by a health care professional who knows the athlete's physical abilities and endurance, such as the school's athletic trainer in collaboration with the school nurse. By gauging the athlete's performance on each individual step, a health care professional will be able to determine how far to progress the athlete on a given day. In some cases, the athlete may be able to work through one step in a single day, while in other cases it may take several days to work through an individual step. It may take several weeks to months to work through the entire five-step progression.

While most athletes will recover quickly and fully following a concussion, some will have symptoms for weeks or longer. Athletes should be referred to a concussion specialist if:

1. Symptoms worsen at any time.
2. Symptoms have not gone away after 10-14 days.
3. The athlete has a history of multiple concussions or risk factors for prolonged recovery. This may include a history of migraines, depression, mood disorders, or anxiety, as well as developmental disorders such as learning disabilities and Attention Deficit Hyperactivity Disorder (CDC, A “Heads Up” on Managing Return to Play).

Current Best Practices in the Prevention and Treatment of a Concussion

Prevention 

There are many ways to reduce the chances of sustaining a concussion during participation in athletic activities. Schools should ensure that during athletic contests and practices, athletes:

• use the correct protective equipment (should be fitted and maintained properly in order to provide the expected protection);
• follow all safety rules and the rules of the sport;
• practice good sportsmanship; and
• do not return to play with a known or suspected concussion until they have been evaluated and given written permission by an appropriate health care professional.

Treatment

Education and recognition are the best tools for improving the care of the athlete with a concussion. Students who have been diagnosed with a concussion require both physical and cognitive rest. Delay in instituting health care provider orders for such rest may prolong recovery from a concussion. The health care provider’s orders for avoidance of cognitive and physical activity and graduated return to activity should be followed and monitored both at home and at school. Districts should consult their school medical director if further discussion and/or clarification is needed regarding a private medical provider’s orders, or in the absence of a private medical provider’s orders. Additionally, children and adolescents are at increased risk of protracted recovery and severe, potentially permanent disability (e.g., early dementia, also known as chronic traumatic encephalopathy) or even death if they sustain another concussion before fully recovering from the first concussion. Therefore, it is imperative that a student is fully recovered before resuming activities that may result in another concussion. Best practice warrants that, whenever there is a question of safety, a health care professional errs on the side of caution and holds the athlete out for a game, the remainder of the season, or even a full year.

Cognitive Rest 

Cognitive rest requires that the student avoid participation in, or exposure to, activities that require concentration or mental stimulation including, but not limited to:

• computers and video games;
• television viewing;
• texting;
• cell phone use;
• reading or writing;
• studying or homework;
• taking a test or completing significant projects;
• loud music; or
• bright lights.

Parents/guardians, teachers, and other school staff should watch for signs of concussion symptoms such as fatigue, irritability, headaches, blurred vision, or dizziness reappearing with any type of mental activity or stimulation. If any of these signs and symptoms occur, the student should cease the activity. Return of symptoms should guide whether the student should participate in an activity. Initially, a student with a concussion may be able to attend school for only a few hours per day and/or need rest periods during the day. Students may exhibit increased difficulties with focusing, memory, learning new information, and/or an increase in irritability or impulsivity. Districts should have policies and procedures in place related to transitioning students back to school and for making accommodations for missed tests and assignments. An Individual Health Care Plan with academic accommodations is an example of a guideline that may be used. If the student’s symptoms last longer than seven to 14 days, a medical provider should consider referring the student for an evaluation by a neuropsychologist, neurologist, physiatrist, or other medical specialist in traumatic brain injury.

Note: Increased cognitive activity, as well as too little cognitive activity, is associated with longer recovery from concussion. Thus, it is desirable to pace a student’s academic load below symptom threshold (Pediatrics 2014; 133:1–6).

Schools are permitted to authorize certain testing accommodations for students who incur an injury within a certain timeframe prior to the test administration. In some situations, a 504 plan may be appropriate for students whose concussion symptoms are significant or whose symptoms last six months or longer. Section 504 is part of the Rehabilitation Act of 1973 and is designed to protect the rights of individuals with disabilities in programs and activities that receive federal financial assistance from the U.S. Department of Education. Section 504 requires a school district to provide a free, appropriate, public education (FAPE) to each qualified student with a disability who is in the school district’s jurisdiction, regardless of the nature or severity of the disability. Under Section 504, FAPE consists of the provision of regular or special education and related aids and services designed to meet the student’s individual educational needs as adequately as the needs of nondisabled students are met. (More information is available on Section 504 law at http://www2.ed.gov/about/offices/list/ocr/index.html. Questions and Answers on Section 504 including information on addressing temporary impairments such as concussions is available at http://www2.ed.gov/about/offices/list/ocr/504faq.html).

Physical Rest

Physical rest includes getting adequate sleep, taking frequent rest periods or naps, and avoiding physical activity that requires exertion. Some activities that should be avoided include, but are not limited to:

• activities that result in contact and collision and are high risk for re-injury;
• high speed and/or intense exercise and/or sports;
• any activity that results in an increased heart rate or increased head pressure (such as
• straining or strength training).

Students may experience frustration or stress about having to limit activities or having difficulties keeping up in school. They should be supported and reassured that they will be able to resume activities as soon as it is safe, and that it is important to avoid activities which will delay their recovery. Students should be informed that the concussion will resolve more quickly when they follow their medical provider’s orders. Students will need encouragement and support at home and school until symptoms fully resolve (CDC, Heads Up: Preventing Concussion).