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UNIVERSITY OF HOUSTON SPORTS MEDICINE DEPARTMENT
CONCUSSION MANAGEMENT PROTOCOL
The University of Houston Sports Medicine Department will follow specific and scientifically based guidelines for proper concussion management including pre-season education, return to learn, and return to play following sports related concussion, under the following concussion management protocol.
With the information published in recent years concerning concussion and potential long term effects, management of concussion has changed. The University of Houston Sports Medicine Department is committed to providing the highest quality of health care for the student-athletes with sport-related head injuries.
The University of Houston Sports Medicine staff including ATCs and medical concussion management team below will approach head injuries, including concussions, in a conservative manner and will follow the proper procedures and management in order to protect student-athletes from unnecessary cumulative effects and second impact syndrome.
Team physician, Director of Athletics, and Head Athletic Trainer provide a signed acknowledgement of having read and understood the concussion management protocol.
MEDICAL CONCUSSION MANAGEMENT TEAM
|Team Physician||Walter Lowe, M.D.|
|Team Physician||David Crumbie, M.D.|
|Team Physician||Mark Chassay, M.D.|
|Team Physician||Jocelyn Szeto, M.D.|
|Team Physician||Kevin Williams, M.D.|
|Team Physician||Andrew Li, M.D.|
With the use of concussion management protocol, the University of Houston Sports Medicine staff will better educate the student-athletes, team physicians, ATCs, coaches and administration on the dangers and risks of head injuries including concussion.
- University of Houston student-athletes will sign an annual statement in which they accept the responsibility for reporting their injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process, student-athletes will be presented with educational material on concussions. NCAA concussion fact sheets or other applicable materials are provided annually.
- University of Houston coaches are educated and they accept the responsibility for reporting suspected head injuries and illnesses to the institutional medical staff, including signs and symptoms of concussions. During the review and signing process, coaches will be presented with educational material on concussions. NCAA concussion fact sheets or other applicable materials are provided annually.
- University of Houston sports medicine staff i.e. ATCs and MDs, will meet annually to discuss and update the concussion EAP. They will go over the most current literature regarding concussion management and policy. The staff will be required to sign-in to this meeting to show proof of attendance. NCAA concussion fact sheets or other applicable materials are provided annually.
- The University of Houston administration i.e. Athletic Director will receive a copy of our annually reviewed concussion EAP and sign their acknowledgment of having read and understand the protocol. NCAA concussion fact sheets or other applicable materials are provided annually.
The entire process, from initial evaluation to final return to play decision, will be documented and placed in the student-athlete's medical record.
The Centers for Disease Control and Prevention (CDC) defines concussion or mild traumatic brain injury (MTBI) as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a blow or jolt to the head that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e., CT scan, MRI). MTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or even longer in some case.
- Concussions or mild traumatic brain injury (MTBI) are typically caused by either a direct blow to the head, face or neck, or a blow elsewhere on the body with an "impulsive" force transmitted to the head.
- Acute symptoms reflect a functional disturbance rather than a structural injury. No abnormality on standard structural neuroimaging studies is generally evident.
- May or may not involve loss of consciousness.
- Rapid onset of short-lived impairment of neurologic function that resolves spontaneously over time (7-10 days), though in some cases a delayed onset of symptoms may occur.
- Resolution of physical and cognitive symptoms typically follows soon after the injury. However, in a small percentage of cases, post-concussive symptoms may be prolonged.
COMMON SIGNS AND SYMPTOMS:
- Loss of consciousness (LOC) or notable change in level of consciousness
- Headache or "pressure in head"
- Nausea and/or vomiting
- Dizziness, balance, coordination problems
- Confusion/blank stare (feeling mentally "slowed down" or "foggy")
- Mental confusion, disorientation, restlessness, increased agitation
- Difficulty with memory, concentration, or focusing on tasks
- Amnesia (either prior to or immediately following the injury)
- Delayed verbal / motor responses
- Sleep disturbances (trouble falling asleep, sleeping more or less than usual
- Blurred vision
- Sensitivity to light or noise
- Anxiety / nervousness
- Depression / sadness / emotional changes
- Combativeness / irritability
Pre-participation guidelines specifies documentation that each varsity student-athlete has received at least one pre-participation baseline concussion assessment including:
- ○ Brain injury and concussion history
- ○ Symptom evaluation
- ○ Cognitive assessment
- ○ Balance evaluation
- ○ Team physician determines pre-participation clearance and/or the need for additional consultation or testing
As part of our protocol, the department staff will provide neurocognitive baseline assessments utilizing ImPACT™ (Immediate Post-Concussion Assessment and Cognitive Testing). This baseline assessment will be administered to the student-athletes of teams which are at high risk for concussive injuries prior to the first season practice. Following a concussion, the department staff will also provide post injury evaluation(s) utilizing the aforementioned assessment and others i.e. SCAT5 (Sports Concussion Assessment Tool) to ensure the safe return of student athletes to full sports participation.
- All student-athletes will receive computer-based ImPACT™ baseline neurocognitive testing.
- Student-athletes who have a history of significant or multiple concussions will be administered a SCAT5 (Sport Concussion Assessment Tool) baseline assessment along with the baseline exam mentioned above. Clearance and need for additional consultation and testing will be determined by the attending team physician at the time of the student-athletes pre-participation evaluation.
- All baseline testing will ideally be completed prior to the first official practice.
- Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be "present" at all NCAA varsity competitions in the following contact/collision sports: basketball; football; pole vault; soccer. To be present means to be on site at the campus or arena of the competition. Medical personnel may be from either team, or may be independently contracted for the event.
- Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be "available" at all NCAA varsity practices in the following contact/collision sports: basketball; football; pole vault; soccer. To be available means that, at a minimum, medical personnel can be contacted at any time during the practice via telephone, messaging, email, beeper or other immediate communication means. Further, the case can be discussed through such communication, and immediate arrangements can be made for the athlete to be evaluated.
- ACUTE / IMMEDIATE EVALUATION - (On-Field / Sideline / Training Room)
- Remove athlete from competition if concussion is suspected.
- Assessment and diagnosis by ATC and/or sideline/clinic physician with concussion assessment experience.
- Athlete should not return to practice or game play on the same day they were injured regardless of how long the concussive symptoms are present.
- Assess level of consciousness - any loss of consciousness, even brief, must be evaluated by a physician with concussion evaluation experience.
- Always assume there is a cervical spine injury until proven otherwise.
- Assess the student-athlete via concussion evaluation map or SCAT5 evaluation, if form is available. Symptom assessment; physical and neurological exam; cognitive assessment; Balance exam.
- Continue to observe athlete for approximately 15-20 minutes, reassessing every 5 minutes for any signs of deterioration. If any signs occur, transport athlete immediately to hospital emergency department via ambulance.
- Closely monitor mental and neurologic status - failure of symptoms to clear or any worsening of symptoms should prompt immediate transport to hospital emergency department for further assessment (GCS < 13, prolonged LOC, focal neurological deficit, repetitive emesis, spine injury, persistent worsening neurological signs and symptoms or mental status).
- Activate the concussion management team (ATC, team physician and/or a neuropsychologist)
- DIFFERENTIAL DIAGNOSIS
- Most concussions do not involve a structural injury to the brain. The following reflect examples of significant head injuries requiring a higher level of care:
- Eliminate C-spine fracture
- Skull fracture
- Obvious scalp / skull deformity
- Ecchymosis (bruising) around the eyes or behind the ears
- Spinal fluid (CSF) leakage from ears or nose
- Student-athletes sustaining a concussion will be assessed and evaluated by a concussion management team (ATC, team physician and/or a neuropsychologist).
- The University of Houston concussion management team is required to have constant communication between the sport ATC and the attending physician.
- The University of Houston concussion management team will follow a concussion management timeline.
- Suspected concussion injury - Assessment and diagnosis by ATC and sideline/clinic physician.
- Perform a post-concussion SCAT5 by a certified athletic trainer or team physician, ideally within 24 hours post-concussion, to establish baseline or compare to the athlete's baseline assessment.
- If necessary - Referral to neuropsychologist or other professional within 24-48 hours.
- ImPACT testing, balance and symptom assessment performed by neuropsychologist and/or designee.
- ImPACT test should not be performed within the 24-48 hours unless directed by a neuropsychologist and/or asymptomatic.
- Ocular or vestibular dysfunction testing and rehab prescription.
- ATC may initiate the student-athlete in RTP protocol when the student-athlete is asymptomatic 2 straight days in a row per team physician's release. Otherwise, concussed athletes should avoid any strenuous physical exertion or activity that worsens symptoms or has the potential to prolong recovery.
- Re-evaluation by attending physician 5-7 days following initial evaluation, if necessary.
- Assessment with attending physician for medication management/therapy referrals, if needed.
- Student-athletes with persistent post-concussion clinical signs or symptoms or a complicated history of concussion, may be referred for other diagnostic tests including neuroimaging (i.e., CT, MRI) or lab work.
- Further evaluation with an appropriate specialist may be arranged to consider additional diagnosis and best course for future management. Other diagnostic considerations may include, yet not limited to: migraine or headache disorders, sleep disorders, ocular or vestibular dysfunction, musculoskeletal injury, mood or adjustment disorders
- Full clearance during the final phases of the RTP, the ATC staff will need the attending physician's final assessment for full contact RTP.
- The SCAT5 Symptom Checklist will be completed by the athlete and reviewed by the certified athletic trainer or team physician on a daily basis in order to track symptom recovery.
- ImPACT™ subsequent post injury tests will be administered on an individual basis and at the recommendation of the attending team physician and consulting neuropsychologist.
According to the Centers for Disease Control and Prevention (CDC), only a trained healthcare professional with experience in concussion management should interpret neurocognitive tests. When possible, ideally a neuropsychologist should interpret the computerized (ImPACT™) or paper-pencil neuropsychological test components. Remember that results of neuropsychological tests should not be used as a stand-alone diagnostic tool, but should serve as one component used by trained healthcare professionals to make a return to school and play decisions.
- Written and verbal home care instructions will be given to the student-athlete and their roommate (or similar second person) to guide care at home until seen at further follow-up care in the training room or physician's office. The medical staff should avoid letting the athlete go home without someone to be able to monitor them overnight. The student-athlete will NOT take any over the counter medications including acetaminophen (Tylenol), ibuprofen (Advil, Motrin, Motrin IB), naproxen sodium (Aleve), or any form of aspirin or pain reliever for reduction of the signs or symptoms of post-concussive injury unless explicitly authorized by the team physician.
- In addition to physical rest, the athlete recovering from a concussion also requires mental/cognitive rest. We will identify a point person to help navigate the return-to-learn process e.g. ATC, academic advisor, per the attending physicians modifications.
- Students recovering from a concussion find it very stressful to keep up with the academic demands while not feeling well physically and cognitively. As such, a stepwise progression back to school and various academic activities yields the best outcome.
- ○ The athlete will receive recommendations from team medical staff regarding restricted or limited use of stimulating activities such as cell phone texting, video games, or television.
- ○ Written documentation pertaining to class attendance and necessary academic modifications will be provided by the team physician and neuropsychologist based on the athlete's cognitive and physical evaluation results and severity of concussion symptoms. Accommodations may include but are not limited to:
- ▪ Preferential classroom seating
- ▪ Extended deadlines to complete projects homework assignments
- ▪ Extended time to complete examinations
- ▪ Ability to take examinations in a separate room away from other to reduce distractions
- ▪ Pre-printed class lecture notes
- ▪ Opportunity to tape record class lectures
- ▪ Limit number of examinations in a 1 week period
- ▪ Excused absence from class if symptoms worsen
- ▪ Ability to make up missed work/examinations gradually
- ○ The athlete's academic advisor will be alerted to the athlete's concussive injury and recommendations by team clinicians for the student athlete's return to learn progression. The academic advisor will seek to ensure:
- ▪ The student athlete's course instructors are aware of accommodations
- ▪ Compliance with ADAAA
- ▪ No academic activity on same day as concussion
- ▪ Student athletes with significant concussive symptoms that are unable to tolerate light cognitive exertion will not be allowed to attend classes and remain supervised at home/dorm
- ▪ Modification of schedule/academic modifications for at least two weeks if not longer based on athlete condition
- ▪ Individualized initial academic plan
- ▪ The athlete's stepwise progression back into classroom activities will be at the combined discretion of the medical staff and academic advisor following a reasonable reduction in symptoms.
- ▪ Identification and engagement of campus resources for cases that cannot be managed through schedule modification/academic accommodations. ADAAA office, Learning specialists, and Office of disability services may be included as the resources
- ○ Re-evaluation and modification of academic activity by academic advisor and/or team physician/neuropsychologist is expected should symptoms worsen or other academic challenges occur.
- ○ A student athlete should not attend practice or team meetings if they are not actively engaged in academic activity or classroom attendance nor should attend games or travel to sport competition with their team.
- ○ Team physician
- ○ ATC
- ○ Psychologist/counselor
- ○ Neuropsychologist consultant
- ○ Faculty athletic representative
- ○ Academic advisor
- ○ Course instructor(s)
- ○ College administrators
- ○ Office of disability services representatives
- ○ Coaches
- The student-athlete will be removed from play and will not be allowed to participate in any physical activities while symptomatic.
- Once the student-athlete is asymptomatic for 2 straight days, the Return-to-Play protocol can be initiated. The department staff will follow the graduated Return-to-Play Protocol (see "Return-to-Play Protocol") for the student athlete to safely return to sports participation.
- The Return-to-Play protocol is a stepwise progression. Each step should take a minimum of 12 to 24 hours to complete in order to evaluate for any post-concussion symptoms that may occur during aerobic activity or between exertional sessions. The student-athlete proceeds to the next level ONLY if asymptomatic with both exertional and cognitive activity i.e. academics at the current level and throughout the recovery period.
- The student-athlete should proceed through the full post-concussion Return-to-Play and Return–to-Learn protocol in approximately one week, given that they are asymptomatic at rest and with provocative exercise throughout each step. However, some concussed athletes may require additional time at each phase thereby the process taking more than one week given their unique injury circumstances.
- If concussive symptoms occur during any of the exertional stages, the student-athlete should discontinue activity and/or cognitive activity until asymptomatic at rest for a minimum of 24 hours. Once symptoms have resolved at rest for 24 hours, then the student-athlete can resume the phase in which the athlete was previously asymptomatic.
|Rehabilitation Stage||Functional Exercise at Each Stage of Rehabilitation||Objective of Each Stage|
|1. No activity||Complete physical and cognitive rest||Recovery|
|2. Light aerobic exercise||Walking or stationary cycling keeping intensity < 70% MPHR for 10-15 minutes;NO resistance training||Increase HR|
|3. Moderate aerobic exercise||Stationary bike, elliptical, jogging keeping intensity < 85% MPHR for 20-30 minutes;Begin light resistance training||Increase HR, Cardiovascular endurance|
|4. Sport-specific, non-contact training drills||General sport-specific drills;NO head impact activities;Continue light resistance training||Add movement|
|5. Sport-specific, light-contact training drills||Progression to more complex, light contact training drills with NO live opponent contact drill, (e.g., passing drills in football, soccer);Progressive return to normal resistance training||Exercise, coordination, and cognitive load|
|6. Full contact practice||Following medical clearance, participate in normal training activities but NO games or competition play||Restore confidence and assess functional skills by coaching staff|
|7. Return to full sports participation||Normal game play as tolerated, monitor symptoms|
PREVENTION OF HEAD INJURIES AND CONCUSSION
While we cannot prevent all concussions, advancing the knowledge of student-athletes and those involved in the health and welfare of the student-athlete may help to avoid recovery complications and minimize catastrophic outcomes should a head injury occur. Prevention begins with the pre-participation physical to obtain a detailed concussion history and any previous neurocognitive data, if possible. Strength and conditioning programs, including neck strengthening exercises, can help the body absorb shock more effectively. Equipment such as custom molded mouth and teeth protectors and helmets provide mechanical protection from physical forces to the head. There is, however, no significant evidence that shows molded mouth guards are better in helping prevent head injury than regular mouth guards nor do either helmets or mouth guards prevent all concussions. Education to the athletes, such as proper tackling techniques in football, is highly stressed. Looking at taking a "safety-first" approach: reducing contact during practice and/or taking the head out of contact. Measures are also taken to prevent premature return to activities after a head injury via multiple objective tests including ImPACT™. The test results are compared to pre-participation baseline test and normative data and interpreted by a neuropsychologist or physician specially trained in concussion management and interpretation of neurocognitive data. Lastly, paying close attention to the adherence to "Inter-association Consensus: Year-round Football Practice Contact Recommendations" and to the adherence to "Inter-association Consensus: Diagnosis and Management of Sport-Related Concussion Best Practices"
|UNIVERSITY OF HOUSTON SPORTS MEDICINE DEPARTMENTCONCUSSION MANAGEMENT INSTRUCTIONS|
Significant blows to the head must be treated with caution. Many of the signs and symptoms of concussion or mild traumatic brain injury (MTBI) may not occur for some time following the injury. Problems could arise over the first 24 to 48 hours, so the student-athlete should not be left alone during that initial interval.
If the student-athlete experiences any of the following signs or symptoms, or if any questions arise concerning their condition, contact your physician or one of the emergency numbers provided for guidance, or proceed immediately to the nearest hospital emergency department.