CMS Concussion Management Plan

The Claremont-Mudd-Scripps Colleges Athletics Department (CMS Athletics) is committed to the safety and welfare of all CMS student-athletes. In conjunction with the NCAA Executive Committee, and inaccordance with the NCAA Concussion Policy and Legislation, Claremont-Mudd-Scripps Colleges Sports Medicine has adapted and implemented a concussion management plan to help prevent, identify, evaluate, and manage concussions sustained by our student-athletes. This protocol is approved by the CMS Team Physicians and it provides the appropriate guidelines that should be followed in the event that a CMS studentathlete suffers a concussion, whether that injury is caused by an athletic or non-athletic related activity. This plan is specific to the CMS athletic population.

What is a Concussion?

A concussion is:

• A change in brain function,
• following a force to the head, which
• may be accompanied by temporary loss of consciousness, but is
• identified in awake individuals, with
• measures of neurologic and cognitive dysfunction.

A concussion is caused by an acceleration, deceleration, or torsional force to the brain that results from the transmitted force of a blow to the body. While the most common mechanism is from a direct blow to the head, a
concussion can also occur from a blow to another part of the body. For example, athletes have been concussed from a body-to-body or body-to-ground collision. Because of the nature of this brain injury, it is important to
understand that it can occur in any sport. The signs and symptoms of neurologic and cognitive dysfunction include:

• Headache
• Dizziness
• Ringing in the ears
• Fatigue/low energy
• Feeling emotional
• Pressure in head
• Abnormal vision
• Feeling slowed down
• Confusion
• Irritability
• Neck pain
• Balance problems
• Feeling like “in a fog”
• Drowsiness
• Sadness/depression
• Nausea
• Sensitivity to light
• Difficulty concentrating
• Trouble falling asleep
• Nervous/anxious
• Vomiting
• Sensitivity to noise
• Difficulty remembering
• Sleeping more than usual
• “Don’t feel right”

While sports concussions most commonly result in rapid onset of signs and symptoms, in some circumstances they may appear hours, or rarely, even days after the injury. Furthermore, these signs and symptoms are not unique to concussions only. For example, the athlete with a common cold may present with many of the same symptoms listed above. This makes the management of the concussed athlete that much more challenging for the healthcare provider.

Co-morbidities must be considered when working with the concussed athlete. These include diagnosis such as learning disabilities, attention deficit hyperactivity disorder (ADHD), seizure disorders, migraine headaches, or
psychiatric disorders. These modifying factors present yet another challenge in the diagnosis and management of concussions. It is important to note that there is no singular test or measure that can accurately identify a concussion. Thus, the CMS Athletics Concussion Management Plan employs the use of a number of assessments along with an indepth clinical evaluation by a physician or other qualified medical practitioner to diagnose a concussion. The information gleaned from these efforts, and from the student-athlete’s specific medical history, will be carefully considered in the design of each student-athlete’s individualized plan for care.
CMS Concussion Management Plan -adopted August 2015 Page 3

The CMS Athletics Concussion Management Plan is comprised of six sections:

1. Education
2. Pre-Participation Assessment
3. Recognition, Evaluation, and Diagnosis of Concussion
4. Post-Consussion Management
5. Academic Accommodations and Return-to-Learn
6. Clearance and Return-to-Play Protocol

Education

1. All CMS student-athletes are provided with a digital copy of the NCAA Concussion Fact Sheet for Student-Athletes [PDF], and are required to watch an online video provided by the NCAA on an annual basis.
2. All CMS student-athletes are required to read and sign a Student-Athlete Concussion Responsibilty Statement on an annual basis. In this statement, the student-athlete acknowledges that he/she has read and understands the concussion fact sheet, watched the video and has completed baseline testing.
3. All CMS coaches are provided with a digital copy of the NCAA Concussion Fact Sheet for Coaches [PDF], and are educated annually on the signs and symptoms of concussion.
4. All CMS coaches are also required to read and sign a Coach/Staff Concussion Acknowledgement Statement   [PDF], in which the coach acknowledges that he/she has read and understands the concussion fact sheet.

Pre-Participation Assessment

1. All new and returning CMS student-athletes will complete a concussion history questionnaire as a part of their medical clearance process.
2. All new and incoming CMS student-athletes involved with high-risk sports will also establish baseline scores on the Graded Symptom Checklist, Standardized Assessment of Concussion (SAC), the Balance Error Scoring System (BESS) and the Glasgow Coma Scale (GCS). These sports include: football, soccer, basketball, water polo, lacrosse, baseball, softball, volleyball, diving, and pole vault.

Recognition, Evaluation, and Diagnosis of Concussion

1. All student-athletes who are experiencing signs, symptoms, or behaviors consistent with a concussion, at rest or with exertion, must be removed from all athletic activity for at least the remainder of that day, and must be referred to a CMS athletic trainer or physician for evaluation.
2. A CMS athletic trainer or physician will evaluate the student-athlete suspected of having a concussion. This initial evaluation will include a:

• Neurological exam
• Symptom assessment
• SAC
• BESS
• GCS
• Additional assessment for possible associated injuries such as neck and spine trauma, skull fracture, and itracranial bleeding

   3. Transportation of the student athlete to the nearest hospital is warranted if any of the following signs or symptoms are present:

• GCS less than 13
• Any loss of consciousness
• Focal neurological deficit
• Repetitive vomiting
• Persistently diminished or worsening mental status or other neurological signs or symptoms
• Potential spine injury

   4. All concussed student-athletes will be evaluated, either in-person or via telemedicine, by the CMS team physician as soon as possible. The physician will then prescribe an individualized management plan for the student-  athlete that may include athletic restrictions and/or academic accommodations.

Post-Concussion Management

1. All student-athletes suspected of sustaining a concussion will be removed from all athletic activity at least for the remainder of that day, and will be evaluated as described above. The student-athlete must refrain from all athletic activity and exercise until cleared by the CMS team physician or their designate.
2. Once it is determined that the student-athlete can be released from the supervision of the CMS athletic trainer, a Concussion Home Care Instructions    [Word doc] sheet will be provided and explained to both the concussed student-athlete and a responsible adult (e.g., parent or roommate) who will continue to monitor the student-athlete.
3. he Sports Medicine Department will report the injury to the Disability Services Office, Dean of Student’s Office and the Student Health Center. Cognitive rest is instrumental during the initial recovery phase, and so appropriate academic accommodations may be recommended. See Academic Accommodations and Return-to-Learn below.
4. Serial evaluation by a CMS athletic trainer will take place on a daily basis, unless otherwise directed by the team physician, in order to assess any deterioration of signs, symptoms, or cognitive function. These evaluations will include at least a symptom assessment, and may include SAC and BESS scores. When available, these scores will be compared to established baseline scores.
5. CMS Athletics is committed to the overall health and well-being of our student-athletes. Thus, in addition to medical treatment, concussed student-athletes may also be referred to the Monsour Counseling & Psychological Services to meet with a counselor. The purpose of this session is to evaluate and address the psychological effects that the injury may have had on the student-athlete. After this initial referral, both the counselor and the student-athlete can decide upon the necessity for subsequent sessions.
6. In some cases, the CMS team physician or their designate may approve a return to light, aerobic, non-contact activity (e.g., stationary bike, elliptical) before full recovery to baseline levels has been attained.

Academic Accommodations and Return-to-Learn

1. The Disability Services Office, in conjunction with the team physician and Sports Medicine Department, will make appropriate recommendations for provisional academic accommodations to the student-athlete’s professors.
2. For the student-athlete who reports moderate to severe symptoms, academic accommodations may begin with a cognitive rest and recovery period of up to seven days post-injury. During this time, the student-athlete may be temporarily excused from classes, assignments, and exams, provided that the injury has been documented with the Sports Medicine Department and Disability Services Office.
3. The student-athlete with only mild symptoms may be allowed to continue academic participation; however, academic accommodations may be recommended depending on the types of symptoms present. See Concussion Academic Accommodations. This Return-to-Learn clearance is contingent on the student-athlete’s symptom status being documented with the Sports Medicine Staff, who will in turn notify the Disability Services Office.
4. Once asymptomatic, if the student-athlete experiences a recurrence of concussion symptoms, the team Physician will be notified and the reinstatement of academic accommodations will be considered.
5. For those student-athletes who present with prolonged symptom and cognitive impairment, the team physician may prescribe a neuropsychological evaluation in order to (a) determine the nature and severity of cognitive impairment, and (b) identify the extent to which psychological issues may be present and may be interacting with the cognitive processes.
6. The Head Athletic Trainer will provide updates to the SHC and Disability Services Office to ensure that the most current and appropriate accommodations are in place for the student-athlete. This updating process will continue until the student-athlete has made a complete return to unrestricted athletic and academic participation.

Clearance and Return-to-Play Protocol

1. Once the student-athlete is asymptomatic and has returned to baseline levels (on SAC, BESS, Vestibular-Ocular-Motor-screening Test and GCS test scores), he/she may be cleared by the team physician or their designate to begin a Return-to-Play Protocol. This protocol is a stepwise progression of exercise, athletic activity, and contact risk that is supervised by the athletic trainer.

Stepwise Return-to-Play Protocol

1. Light aerobic exercise (e.g. walking, swimming, or stationary cycling; no resistance training)
2. Mode, duration, and intensity-dependent exercise based upon sport
3. Sport-specific activity with no head contact
4. Non-contact sport drills and resumption of progressive resistance training
5. Full-contact practice
6. Return to play
7. Each student-athlete’s Return-to-Play Protocol will be individualized within the general outline indicated above. Special consideration will be given to the athlete’s sport, level and duration of concussive symptomology, and any present modifiers (e.g., previous concussion, history of migraine headaches, ADHD, learning disabilities) when customizing the protocol.

2. Each student-athlete’s Return-to-Play Protocol will be individualized within the general outline indicated above. Special consideration will be given to the athlete’s sport, level and duration of concussive symptomology, and any present modifiers (e.g., previous concussion, history of migraine headaches, ADHD, learning disabilities) when customizing the protocol.
3. It is important that the student-athlete must remain symptom-free throughout the execution of the Return-to-Play Protocol. Thus, the student-athlete will report symptom scores to the athletic trainer both beforeand after the exercise prescription in each step.
4. If at any point, the student-athlete becomes symptomatic, or scores on clinical/cognitive measures decline, the team physician must be notified and the student-athlete returned to the previous step of activity.
5. Final medical clearance for unrestricted return to play will be given by the team physician, or the athletic trainer in consultation with the team physician.

This CMS Concussion Management Plan was adapted by the CMS Sports Medicine staff and CMS team physicians from the Concussion Management Plan developed at Occidental College by the Sports Medicine staff and Vernon Williams, MD.

Concussion Academic Accommodations

Concussion Symptom List and Categories

Suggested Accommodations

Physical Symptoms

• Remove from physical activity without penalty.
• Sit out of music and computer classes if symptoms are provoked.
• Allow rest breaks during class.
• Allow wearing of sunglasses, both outdoors and indoors.

Emotional Symptoms

• Allow student to remove him/herself from class to de-escalate. Student can establish a “signal” letting the professor know that he/she is leaving the room because of escalating symptoms.
• Understand that mental fatigue can manifest in “emotional meltdowns.”
• Watch for secondary symptoms of depression and anxiety usually due to social isolation and concern over “make-up” work and slipping grades.

Sleep/Energy Symptoms

• Allow rest breaks during class.
• Alternate “mental challenge” with “mental rest.”
• Allow student to leave class early.

Cognitive Symptoms
1. Feeling slowed down. (Area of Concern: Slowed processing speed)

• Provide extra time for tests and assignments.
• Adjust (postpone) due dates/test dates, especially during the first-week critical recovery period.
• Provide a peer note-taker or additional notes, if possible.
• Reduce the cognitive load and apply flexibility with assignments (smaller amounts of learning will need to take place during recovery).

2. Difficulty concentrating, feeling like in a “fog,” “don’t feel right.” (Area of Concern: Difficulty concentrating)

• Reduce the cognitive load and apply flexibility with assignments (smaller amounts of learning will need to take place during recovery).
• Consider: what is the most important concept for the student to learn during this recovery?
• Be careful not to tax the student cognitively by expecting that all learning continue at the rate prior to the concussion.

3. Difficulty remembering. (Area of Concern: Difficulty with working memory)

• Work toward comprehension of smaller amounts of material versus rote memorization.
• Remove “busy” work that is not essential for comprehension. Making the student accountable for all work missed during the recovery period places undue cognitive and emotional strain on him/her and may hamper recovery.
• Consider: what is the most important concept for the student to learn during this recovery?

4. Confusion. (Area of Concern: Emotional)

• Be mindful of emotional symptoms throughout! Students are often scared, overloaded, frustrated, irritable, angry and depressed as a result of concussion. They respond well to support and reassurance that what they are feeling is often the typical course of recovery.
• Watch for secondary symptoms of depression - usually from social isolation.
• Watch for secondary symptoms of anxiety - usually from concerns over make-up work or slipping grades.