Concussion Safety Protocol

Ohio Wesleyan University is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. To this end, and in accordance with NCAA legislation, Ohio Wesleyan University  has adopted the following Concussion Safety Protocol for all NCAA student-athletes.

This protocol identifies expectations for institutional concussion management practices as they relate to (1) the definition of sport-related concussion; (2) independent medical care; (3) preseason education; (4) pre-participation assessment; (5) recognition and diagnosis; (6) initial suspected concussion evaluation; (7) post-concussion management; (8) return-to-learn management; (9) return-to-sport management; (10) reducing head impact exposure; and (11) written certificate of compliance signed by the athletics health care administrator.

Background

Definition of Sport-Related Concussion

Sport-related concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities. This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain. Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged. Symptoms include but are not limited to: headache, nausea, sensitivity to light/noise, fatigue, drowsiness, irritability, and feeling slowed down and/or foggy. Concussions are not graded based on symptoms or loss of consciousness at the time of injury.

No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging T1- and T2-weighted images), but in the research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Sport-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness. The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as psychological factors or coexisting medical conditions).

Independent Medical Care

As required by NCAA Independent Medical Care legislation, Ohio Wesleyan University team physicians and athletic trainers shall have unchallengeable autonomous authority to determine medical management and return-to-activity decisions, including those pertaining to concussion and head trauma injuries, for all student-athletes.

What is Second Impact Syndrome?

Second Impact Syndrome (SIS) occurs when an athlete, who has already sustained a head injury, sustains a second head injury prior to complete resolution of symptoms. This often occurs because a person has returned to participation too soon. Most persons do not realize that it may take days and weeks for concussion symptoms to resolve. Second Impact Syndrome most likely affects young athletes (jr/sr high school), however, any athlete who returns to play too soon is a possible candidate. Second Impact Syndrome is a very serious condition that has been linked to permanent brain damage or even death.

What is Neurocognitive Testing?

Given these outlined concerns and inherent difficulties in managing concussion, individualized and comprehensive management of concussion is optimal. This plan can help to objectively evaluate the concussed athlete's post-injury condition and track recovery for safe return to play, thus preventing the cumulative effects of concussions. ImPACT is a user-friendly computer based testing program specifically designed for the management of sports-related concussion. The instrument has been designed after approximately 10-years of university-based, grant-supported research. ImPACT is currently the most widely utilized computerized program in the world and is implemented effectively across high school, collegiate, and professional levels of sport participation.

What is Balance Error Scoring System (BESS) Testing?

The Balance Error Scoring System (BESS) provides a portable, cost effective, and objective method of assessing static posture stability. In the absence of expensive, sophisticated postural stability assessment tools, the BESS can be used to assess the effects of mild head injury on static postural stability. Information obtained from this clinical balance tool can be used to assist clinicians in making return to play decisions following mild head injury. The BESS can be performed in nearly any environment and takes approximately 10 minutes to conduct.

State of Ohio House Bill 143

In April of 2013 the General Assembly of the State of Ohio enacted Ohio House Bill 143—aimed at making youth sports safer. The bill requires all coaches and referees involved in youth sports to receive training in how to recognize the symptoms and signs of a concussion or head injury or hold a current Pupil Activity Permit (PAP) obtained through the Ohio Department of Education. Training in the recognition of a concussion or head injury is offered online by the Ohio Department of Health. In order to obtain a PAP, applicants are required to complete concussion and head injury recognition training.

Athletic Department – Concussion Education

Student-Athletes

All NCAA student-athletes will be provided and allowed an opportunity to discuss concussion educational material (e.g., the NCAA Concussion Education Fact Sheet) or other applicable material. They will be required to sign an acknowledgement, on an annual basis and prior to participation, that they have been provided, reviewed and understood the concussion education material. This information will be distributed via Healthy Roster and will require a signature in order for the form to be submitted and approved. This form also provides a direct link to the NCAA Concussion Resource page. A pre-participation physical examination or participation in team related physical activities will not be permitted until this form is completed.

Athletic Department Staff

All coaches, team physicians, athletic trainers, directors of athletics and other personnel involved in NCAA student-athlete health and safety decision making will be provided and allowed an opportunity to discuss educational material (e.g., the NCAA Concussion Education Fact Sheet) or other applicable material and will be required to sign an acknowledgement, on an annual basis, that they have been provided, reviewed and understood the concussion education material.

Pre-Participation Assessment

All NCAA student-athletes will undergo a pre-participation baseline concussion assessment. This assessment assumed individualized medical care, which means: Each athlete and each injury are different. Depending on the severity of prior injuries, the number of concussions, other individual concerns and based on the developing state of science, the team physician/primary health care provider should review each athlete's history and consider discussing with the student-athlete concerns about concussion and repetitive head impact as warranted, including potential risks and benefits from playing sport. Such discussion allows the athlete to make an informed decision about their participation in sport.

This pre-participation assessment will be conducted via Ohio Wesleyan University and, at a minimum, will include assessment for the following:

  • History of concussion or brain injury, neurologic disorder, and mental health symptoms and disorders: Medical History on yearly PPE forms
  • Symptom evaluation: ImPact Baseline Test
  • Cognitive assessment: ImPact Baseline Test
  • Balance Evaluation: BESS Test

The team physician will determine pre-participation clearance and/or the need for additional consultation or testing and will consider a new baseline concussion assessment at six months or beyond for any NCAA student-athlete with a documented concussion, especially those with complicated or multiple concussion history. Importantly, baseline testing may inform post-injury evaluation; however, student-athletes who have suffered a concussion may perform at the same level or even better than their baseline testing, as motivation and other factors may differ in post-concussion testing. Ultimately, baseline testing serves as one of many potential factors in making a clinical decision.

Sport Coverage for Concussion Management

Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be present at all Ohio Wesleyan University competitions in the following contact/collision sports: Sports Include: baseball; basketball; diving; field hockey; football; lacrosse; pole vault; soccer; softball; volleyball; wrestling.

NOTE: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 Ohio Wesleyan University practices in the following contact/collision sports: Sports Include: baseball; basketball; diving; field hockey; football; lacrosse; pole vault; soccer; softball; volleyball; wrestling).

NOTE: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 and that the case can be discussed through such communication, and immediate arrangements can be made for the athlete to be evaluated.

Recognition and Diagnosis of Concussion

Any Ohio Wesleyan University student-athlete that exhibits signs, symptoms or behaviors consistent with concussion must be removed from practice or competition for evaluation. Examples of signs that warrant immediate removal from the field include: actual or suspected loss of consciousness, seizure, tonic posturing, ataxia, poor balance, confusion, behavioral changes, amnesia.

Concussion Evaluation:

  • Must be evaluated by an athletic trainer or team physician (or physician designee) with concussion experience.
  • Allow ample time when conducting a multi-modal screen to evaluate a potential concussion.
  • Must be removed from practice/play for that calendar day if concussion is confirmed or suspected.
  • May only return to play the same day if the athletic trainer, team physician or physician designee determines that concussion is no longer suspected after evaluation. Even in such cases, consider next day follow-up assessment because initial symptoms may not appear for several hours.

Initial Suspected Concussion Evaluation

Student-athletes will be immediately removed from play and assessed for possible transport to a local hospital/trauma center when any of the following signs/symptoms/behaviors are present:

  • Neck pain or tenderness.
  • Seizure or convulsion.
  • Double vision.
  • Loss of consciousness.
  • Weakness or tingling/burning in more than one arm or in the legs.
  • Deteriorating conscious state.
  • Vomiting.
  • Severe or increasing headache.
  • Increasingly restless, agitated or combative.
  • Glasgow Coma Scale Score <15.
  • Visible deformity of the skull.

An initial concussion evaluation will include an immediate assessment/neurological screen for "red flags" or observable signs. This involves a multi-modal evaluation as clinically indicated such as:

  • Clinical assessment to rule out cervical spine trauma, skull fracture, intracranial bleed or other catastrophic injury.
  • Symptom assessment. SCAT6
  • Physical and neurological exam. SCAT6
  • Cognitive assessment. SCAT6
  • Balance exam.

Upon completing a multi-modal evaluation, the student-athlete will be given an educational sheet about concussions, which will also include a date, time, and location of follow-up with a member of the Medical Staff (Appendix A). Because symptoms may evolve or manifest over time, this informational sheet will be provided to all suspected concussions. Once they meet with a Team Physician a concussion will either be diagnosed or not.

Post-Concussion Management

Acute Concussion

For all cases of a diagnosed concussion, there will be documentation that post-concussion plan of care was communicated to both the student-athlete and another adult responsible for the student-athlete, in oral and/or written form. This meeting could occur with the student-athlete off-field the same day and up to 72 hours in an Athletic Training Room. This will be conducted by having a SCAT 6 performed at a time and place conducive for the extent of the test.

Sub-Acute Concussion

The SCOAT6 will be utilized in situations where the student-athlete experiences a possible concussion and either did not disclose the information to a staff member of the Ohio Wesleyan University Department of Athletics and its Medical Team or the injury occurred over an extended break from school (ie. Fall, Thanksgiving, Winter, or Spring Break).

The SCOAT6 includes a mechanism for evaluation and monitoring of the following:

  • Symptom evaluation.
  • Immediate and delayed memory.
  • Concentration.
  • Orthostatic vital signs.
  • Cervical spine assessment.
  • Neurological evaluation.
  • Balance and tandem gait assessment.
  • Modified VOMS.

In addition, the subacute management plan will consider evaluating for the following, as clinically indicated:

  • Screen for fear, anxiety or depression or other mental health issues.
  • Screen for sleep disturbance.
  • Graded aerobic exercise testing.

Re-Evaluation

Re-evaluation of a concussion will take place on a daily basis with student-athletes completing a Concussion Symptom and Return to Play Progression sheet with an AT staff member. Re-evaluation with a Team Physician will take place on a weekly basis or at the discretion of the team physician who performed the initial concussion evaluation.

During this time, the student-athlete will be able to perform Steps 1, 2 (A&B), and 3 as outlined in the Return to Play section later in this document. They will also be advised on screen time (computers, phones, tablets) as needed by a member of the Medical Team.

Return-to-Learn Management

The vast majority of young adults have a full return-to-learn with no additional academic support by 10 days post-injury. Complete rest and isolation should be avoided, even during the initial 24-48 hours post-injury. Relative rest is important in the first 24 hours. For those student-athletes with persisting symptoms a more formal plan may be in order.

The Return-to-Learn Management Plan will be directed by a point person, which will be the Ohio Wesleyan University Team Physician that is overseeing the injury. The management plan will follow an individualized and step-wise process that will navigate return-to-learn with the student-athlete and, in more complex cases of prolonged return-to-learn, work in conjunction with a multi-disciplinary team that may vary student-to-student depending on the specifics of the case. This multi-disciplinary team may include, but is not limited to:

  • Team physician.
  • Athletic trainer.
  • Psychologist/counselor: On Campus resources include the Student Health Center and Counseling Center.
  • Neuropsychologist.
  • Medical specialists.
  • Faculty athletics representative.
  • Academic counselor.
  • Course instructor(s).
  • College administrators.
  • Office of disability services representative.
  • Coaches.

A student-athlete who has suffered a concussion will return to classroom/studying as tolerated with modification of schedule/academic accommodations, as indicated, with help from the identified point-person (OWU Team Physician). The plan may address environment, physical, curriculum and/or testing adjustments. Campus resources will be engaged for cases that cannot be managed through schedule modification/academic accommodations. The on-campus resources that will be utilized with be the Accessibility Service Office (ASO) through the Office of Student Success. The accommodations outlined by the Team Physician will be sent to the ASO, with the ASO reaching out to student-athletes directly for follow-up appointments.

A student-athlete will be re-evaluated by a team physician (or their designee) and members of the multi-disciplinary team, as appropriate, if concussion symptoms worsen with academic challenges or in the event of atypical presentation or persisting symptoms.

Academic Accommodations – Final Exams

If a student were to sustain and be diagnosed with a concussion and have symptoms that would interfere with their ability to complete finals the following would occur:

  • Prior to leaving campus for winter or summer break the student would meet with the Health Care Provider to receive documentation that they are not able to complete final examinations.
  • The student would meet with the ASO to have them contact Faculty members.
  • A plan would be designed to complete exams upon resolution of symptoms, if that occurs over break.
  • If symptoms do not resolve over break, upon returning to campus the student would have a follow-up with the Health Care Provider. Documentation would again be given to the student on the plans for final examinations as determined by the Health Care Provider. The student would meet with the ASO for communication to faculty members from previous and current semester.

When the student is cleared by the Health Care Provider and ready to take final examinations from previous semester, coordination of any exam scheduling and proctoring will be decided by the student, Coordinator of the DSC, and faculty member.

Return to Learn modifications will be discontinued when the athlete reports no longer experiencing any concussion related symptoms to the medical team.

Return-to-Sport (RTS) Management

Unrestricted return-to-sport should not occur prior to unrestricted return-to-learn for concussions diagnosed while the student-athlete is enrolled in classes. Complete rest and isolation should be avoided, even for initial 24-48 hours. Relative rest is important in the first 24 hours. A proper RTS management plan is important to prevent multiple concussions occurring and Second Impact Syndrome. Final determination of unrestricted return-to-sport will be made by an Ohio Wesleyan University team physician or their medically qualified designee following implementation of an individualized, supervised stepwise progression management plan that includes:

  • Step 1. Symptom-limited activities of daily living. (ex. walking)
  • Step 2. Aerobic exercise with light resistance training as tolerated [no more than mild or brief (<1 hour) exacerbation of symptoms].
    • 2a. Light (up to approximately 55% maximum heart rate on stationary bike); then
    • 2b. Moderate (up to approximately 70% maximum heart rate on stationary bike).
  • Step 3. Individual sport-specific exercise and activity without any increased risk of inadvertent head impact exposure. (ex. Running, change of direction, and/or individual training drills)

Proceed to step 4 only after resolution of signs and symptoms related to the current concussion, including with and after physical exertion.

  • Step 4. Non-contact practice with progressive resistance training.
  • Step 5. Unrestricted practice or training.
  • Step 6. Unrestricted return-to-sport.

The above stepwise progression will be supervised by a member of the Ohio Wesleyan University Athletic Training staff, with it being typical for each step in the progression to last at least 24 hours.

NOTE:If at any point the student-athlete becomes symptomatic (more symptomatic than baseline), the team physician or physician designee will be notified, and adjustments will be made to the return-to-sport progression. * For example, testing stops with an increase of more than 2 points on a 0 to 10 point scale when compared with the pre-exercise resting value.

The RTS progression will be documented on the Concussion Symptom and Return to Play Progression (Appendix B) sheet. The spaces at the bottom of the sheet will be utilized to document the step performed, activity performed, student-athletes "% of feeling normal" both prior to and after activity, and if symptoms that worsened more than two points on a 1-10 scale did they resolve in less than two hours.

Reducing Head Impact Exposure

Ohio Wesleyan University is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. To this end and in accordance with NCAA association-wide policy, Ohio Wesleyan University will reduce student-athlete head impact exposure in a manner consistent with Interassociation Recommendations: Preventing Catastrophic Injury and Death in Collegiate Athletes and Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport. For example:

  • Ohio Wesleyan University teams will adhere to existing ethical standards in all practices and competitions.
  • Using playing or protective equipment (including the helmet) as a weapon will be prohibited during all practices and competitions.
  • Deliberately inflicting injury on another player will be prohibited in all practices and competitions.
  • All playing and protective equipment (including helmets), as applicable, will meet relevant equipment safety standards and related certification requirements.
  • Ohio Wesleyan University will keep the head out of blocking and tackling in contact/collision, helmeted practices and competitions.
  • Ohio Wesleyan University will emphasize education of proper technique to reduce head impact exposure for all contact and collision sports, with special emphasis in pre-season.
  • Ohio Wesleyan University will adhere to policies and rules in sport that limit the number and duration of contact practices and activities in contact-collision sports.
  • Consideration of participation in neuromuscular training warm-up programs.

Youth Sports Organizations

Ohio Wesleyan University offers and sponsors many sports camps or workshops for youth participants throughout the school year. To remain in compliance with Ohio House Bill 143, the director of each youth sports organization will be responsible to ensure the following practices are being met:

  • Every Coach (paid or volunteer) and Official (if applicable) involved with the program submits a copy of either a Pupil Activity Permit (PAP) from the State of Ohio Department of Education OR a copy of completion an online concussion training program to the camp or organization director.
  • Provide a copy of an informational handout on concussions and head injuries (Appendix D) developed by the CDC to every parent/legal guardian of any athlete who is participating in the programs being offered by the organization.
  • Ensure that any participant that is exhibiting the signs and symptoms of a concussion be removed from participation for that day. A letter of clearance from a physician MUST be received in order for the participant to return to activity.