Your school’s concussion protocol is your first line of defense when a concussion occurs. It’s your set policies, tools, and assessments that you’ll turn to as you respond to an injury. While the word ‘protocol’ may seem overly strict, your concussion protocol is anything but – it simply is another tool in your toolkit to provide an individualized, patient-centered approach to concussion management. But your concussion protocol not only serves as this vital framework for concussion care, but it also protects you from risk. Having a concussion protocol means you have an outline of the proper communication and documentation necessary to fully evaluate, manage, and treat concussions. Legally, athletic trainers have a duty of care and are held to the standards outlined by the NATA Position Statement: Management of Sport Concussion. This position statement reads:
“The athletic trainer should ensure proper documentation of the concussion evaluation, management, treatment, return to participation progression, and physician communications”. - NATA Position Statement: Management of Sport Concussion
Having a concussion policy in place not only ensures athlete safety but protects the athletic trainer and school from liability as well.
For a concussion policy to be effective, it should do the following:
- Integrate new knowledge about concussion as a mild traumatic brain injury (MTBI)
- Require concussion management training for coaches, athletes, and parents of athletes,
- Require a signed medical release before clearance to play
- Require that the student be symptom-free before final clearance to participate
- Require recommended protocols for return to activity and return to academics
A comprehensive concussion management plan includes several individuals that form a multi-disciplinary concussion management team. In a school setting, this team is usually composed of athletic trainers, school personnel, team physicians, coaches, and parents. Once the concussion management team is assembled, this team will agree on the key concussion protocol steps for the school. Every school’s concussion protocol will vary depending on state or local laws.
Concussion Communication & Preparticipation Testing:
Communicating to a school about concussion management goes beyond treating the patient and communicating with key stakeholders. In most concussion policies, the definition of a concussion is included alongside the signs, symptoms, and immediate recognition steps that will be used. It is also important to define how this information will be communicated to others for educational purposes. The importance of reporting concussion symptoms should be highlighted in these educational opportunities. Coaches, athletes, and parents should all receive information about concussions and concussion management policies. Most schools will require a concussion acknowledgment form to be signed prior to participation, and concussion management training or certification from coaches before they can start their season.
Pre-participation baseline testing protocols should be outlined in your concussion management policy. For most, baseline testing is recommended to be completed annually so there is always an up-to-date record of the patient’s current normal level of function. Depending on the baseline testing methods you choose, this information should be included in the concussion policy and protocol, as well as who is allowed to administer baseline and post-injury tests and interpret the results of those tests. The Sway System incorporates both objective balance and objective cognitive measures, as well as symptom tracking.
Your concussion protocol should include how concussions are documented and how a concussion is communicated to key personnel. Many athletic trainers choose to use both phone and email so there is an electronic record of communication. The most vital piece of communication is that the athlete is not to participate in sports, physical education classes, or sports activities outside of school until the athlete is fully cleared to participate by the healthcare provider indicated as eligible to make this decision in your protocol.
Initial Concussion Evaluation
Your sideline evaluation is important for discovering concussions early and determining the next step in the athlete’s care. Without this initial assessment, the athlete is at risk of further injury or even death if they were to continue to play or return prematurely. An initial evaluation should include a symptom check and measures of cognitive functioning and balance. Decisions on removal from play or the need for a trip to the ER are made based on the findings. The Sway System makes on-field assessments simple by integrating red flag symptoms that warrant further emergent care, a Maddocks assessment, observable signs, a cervical spine assessment, and the Glasgow Coma Scale. Because the assessment can be completed on a mobile device, there is no need for loose papers or a computer, allowing healthcare providers to cut the cord from cumbersome prior methods of on-field testing.
The NATA concussion position statement outlines the initial injury evaluation components and includes the injury mechanism, initial signs and symptoms, state of consciousness, and physical and neurologic examination findings. The position statement also recommends documentation of athlete and parent instructions that were given, physician recommendations, any relevant history, and return to play information. Additional information about follow-up evaluations, communication with others, and recommendations should also be documented. Your concussion protocol should include a copy of the home care instructions that are given to athletes and parents following a concussion.
Return to Play & Learn/Work
Not having adequate documentation of your return to play process creates a liability risk. A form or other electronic record should be used to document and date the specifics of each step of your return to play protocols and procedures. These documents should be kept in the athlete’s record. Any signs or symptoms that recur, results of any neurocognitive or balance testing, and other notes should be included. Communication with the athlete, parents and any other relevant healthcare providers should be documented as well. Typically, a return to play protocol follows these steps:
- Symptom-limited activity
- Light aerobic exercise
- Sport/activity-specific exercise
- Non-contact training drills
- Full contact practice
- Full return to play
Working with school personnel, a protocol and communication plan for academic restrictions should be created. This policy should be specific on who can authorize and adjust any academic or work restrictions, including the steps taken to extend any accommodations needed for the athlete. Based on the terminology from the American Academy of Pediatrics, academic restrictions are non-formal adjustments made during the initial 1-3 week recovery period, while academic accommodations are those that extend beyond 3 weeks.
Once repeat evaluations and neurocognitive testing indicate the athlete may be ready to return to play, it must be determined that the athlete is fully asymptomatic and has been fully cleared by the appropriate healthcare provider. Some state or local laws may require a physician to determine if the athlete is ready to return to play. This should also be documented in your concussion protocol.
Each and every concussion is different. It takes many people to manage a concussion management multi-disciplinary team effectively. Remember, your protocol should always be developed with the best interests of the athlete, the school, and all healthcare providers in mind. Communication, documentation, and being proactive with your protocol are key.