Concussion Management Policy

  • Concussion Policy #7515:  City School District of the City of Niagara Falls

     Concussion Management policy for athletic training contracts with NFMMC

     The following policy is for schools, organizations, and tournaments that are under contract for athletic training services with Niagara Falls Memorial Medical Center (NFMMC) and in affiliation with UB Orthopedics & Sports Medicine of Niagara.  NFMMC employs certified athletic trainer(s) for contracted services at the school for sports medicine.  This policy is based on the Summary and Agreement statement of the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  This conference also updated the SCAT32 form to the SCAT53 which is now the recommended concussion evaluation tool of choice along with ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) computer testing. 

     This concussion policy is for students and student athletes from the Niagara Falls City School District (NFCSD) in grades K-12. 

     Definition of concussion:

     Concussion is a mild traumatic brain injury.  Concussion occurs when normal brain functioning is disrupted by a blow or jolt to the head, face, neck or elsewhere on the body with an ”impulsive” force transmitted to the head .  Recovery from concussion will vary.  Avoiding re-injury and over-exertion until fully recovered are the cornerstones of proper concussion management.

     Defining the nature of a concussive head injury includes: 

    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 neurologic function that resolves spontaneously.
    3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
    4. Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness.  Resolution of the clinical and cognitive symptoms typically follows a sequential course.
    5. Concussion is typically associated with grossly normal structural neuro-imaging studies. 

    Pediatric Concussive injury: 

    Children, ages (5-18) years old should not be returned to playing or training until clinically completely symptom free.  Because of the physiological response during childhood head trauma, a conservative return to play approach is recommended.  It may be appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents.  It is not appropriate for a child or adolescent athlete with concussion to Return to Play (RTP) on the same day as the injury, regardless of the level of athletic performance.  Concussion modifiers apply even more to this population than to adults and may mandate more cautious RTP advice.  In addition, the concept of “cognitive rest” is highlighted, with special reference to a child’s need to limit exertion with activities of daily living and to limit scholastic and other cognitive stressors (eg, text messaging, video games, etc.) while symptomatic.  School attendance and activities may also need to be modified to avoid provocation of symptoms.   

    Concussion Evaluation: 

    The diagnosis of acute concussion usually involves the assessment of a range of domains, including clinical symptoms, physical signs, behavior, balance, sleep, and cognition.  Also, a detailed concussion history is an important part of the evaluation, both in the injured athlete and when conducting a pre-participation examination. 

    The suspected diagnosis of concussion can include one or more of the following clinical domains: 

    1. Symptoms: somatic  (eg, headache), cognitive (eg, feeling “like in a fog”) and/or emotional symptoms (eg, lability)
    2. Physical signs (eg, loss of consciousness, amnesia)
    3. Behavioral changes (eg, irritability)
    4. Cognitive impairment (eg, slowed reaction time)
    5. Sleep disturbance (eg, drowsiness)
    6. If any one or more of these components is present, a concussion should be suspected and the appropriate management strategy instituted. 

    Grading concussions: 

    With concussion, an athlete suffers an injury that progressively resolves without complication over 7-10 days.  Concussion represents the most common form of this injury and can be appropriately managed by primary care physicians or by certified athletic trainers working under medical supervision.  Concussion management ideally is rest until all symptoms resolve and then a graded program of exertion before return to sport.  All concussions mandate evaluation by a medical doctor who is comfortable in managing concussion injuries. 


    Neuro cognitive testing: 

    NFCSD will implement Neuro-cognitive computer based testing.  We will use the ImPACT concussion management program for baseline evaluations for NFCSD student athletes for grades 7-12.  We will do post-injury evaluations with the SCAT5 form and ImPACT program as objective tools in the concussion management process to determine a safe return to play for the student athlete.  NFCSD will concussion baseline test those contact sport student athletes from football, soccer, wrestling, hockey, and lacrosse.  We will also baseline test athletes from boys and girls basketball and cheerleading.  This will include modified, JV, and Varsity student athletes.  Those athletes not participating in those above sports are able to have a concussion baseline test completed, if desired.  Those student athletes that have a history of (1) prior concussion will also be required to receive a concussion baseline test from the ImPACT program. 

    Computer baseline testing allows us to: 

    • Quantify the injury with a highly sensitive measure of brain function
    • Protect the athlete
    • Help determine safe return to play
    • Help prevent cumulative effects of multiple concussions
    • Prevent lingering effects of concussion and potential catastrophic injury

     Return to play PROTOCOL

    During the period of recovery, in the first few days following the injury, it is important to emphasize to the athlete that physical AND cognitive rest is required.  Activities that require concentration and attention may exacerbate the symptoms and as a result delay recovery. 

    Pharmacological therapy: 

    An important consideration in RTP is that concussed athletes should not only be symptom free, but also should not be taking any pharmacologic agents or medications that may mask or modify the symptoms of concussion.  Where antidepressant therapy may be commenced during the management of a concussion, the decision to RTP while still on such medication must be considered carefully by the treating clinician. 

    A player should never return to play while symptomatic.