College Station Independent School District · Richard Smith, MD Concussion Oversight Team Member...

College Station

Independent School

District

Concussion

Management Guide

COLLEGE STATION ISD SPORTS MEDICINE

INFORMATION FOR PARENT/GUARDIAN

College Station ISD - 2014

BACKGROUND

The College Station ISD Athletic Training and Sports Medicine Program has developed and implemented

the following concussion management guidelines for the student athletes in College Station ISD in

accordance with the rules set forth by the University Interscholastic League and SB 2038, or Natasha’s

Law. These comprehensive guidelines are consistent with current standards of care and appropriate

medical practices for the student athlete who suffers a concussion in sports. Developed and implemented

by the Concussion Oversight Team (COT), the following guidelines are designed to facilitate a safe return

to athletic activities for the student athletes of College Station ISD. The COT is committed to utilizing

current standards and methods in its multidisciplinary approach to concussion management including:

ImPACT and/or C3 Logix pre- and post-injury neurocognitive testing, symptom assessment tools, and a

progressive return-to-play protocol.

INSIDE THIS PACKET

Inside this packet you will find information for you as the parent/guardian, information for the treating

physician, results for neurocognitive testing, and the required documentation that must be turned back in

to the athletic trainers’ office.

1. Post-concussion Management Guide – general information regarding CSISD’s concussion

management protocol.

2. Concussion Return-to-Play (RTP) Consent – must be signed and returned once your child has

completed the RTP protocol.

3. UIL Return-to-Play Form – must be signed and returned once your child has completed the

RTP protocol.

4. Participating Providers – list of physicians familiar with the CSISD concussion management

protocol.

5. Information for Treating Physician – the front of this page is information on CSISD’s return-

to-play guidelines. The back side of the page must be filled out and returned at 4 steps of the

process. (Whether or not an appointment is needed for steps b-d is at the physician’s discretion.)

Athlete will not move on to next step without this documentation on file with athletic trainers.

a. Initial Diagnosis

b. When athlete is symptom free and may begin RTP protocol

c. When athlete is symptom free and ready to begin full-contact portion of RTP

d. When athlete has completed the return-to-play protocol and may resume

unrestricted athletic activity.

6. Neurocognitive Test Results – these documents help your treating physician get a feel for

symptoms initially reported, as well as sideline assessments and neurocognitive testing performed

post-injury.


INFORMATION FOR PARENT/GUARDIAN


PHYSICIAN REFERRAL CHECKLIST

Signs and symptoms of a closed head injury do not always present until hours or sometimes days after the

initial trauma. Due to this fact, you should be aware of possible signs and symptoms that indicate an

emergency including but not limited to the following.

Emergency Signs and Symptoms

One pupil larger than the other

Excessive drowsiness or unconsciousness

that cannot be awakened

A headache that gets worse and does not go

away

Repeated vomiting or nausea

Slurred speech

Difficulty walking

Difficulty recognizing familiar people or

places

Convulsions or seizures

Increasing confusion, restlessness or

agitation

Unusual behavior

Bleeding or drainage or fluid coming from

the nose or ears

INSTRUCTIONS FOR HOME

After sustaining a concussion it is important to provide the best atmosphere for recovery. Please consider

the recommendations below to help your child in the healing process.

1. Please review the items outlined on the Physician Referral Checklist. If any of these problems

develop, please call 911 or your family physician.

2. Things that are OK to do:

a. Take acetaminophen (Tylenol)

b. Use ice packs on head or neck as needed for comfort

c. Eat a light diet

d. Go to sleep (rest is very important)

e. Wake up/recheck athlete only when experiencing moderate-severe symptoms

f. Return to school

3. Things that should not be allowed:

a. Drive a vehicle

b. Eat spicy foods

c. Watch TV or play video games (including games on phone)

d. Read, write, or text

e. Listen to music, talk on telephone

f. Use a computer

g. Bright lights/loud noise

h. Strenuous activity or sports

i. Drink alcohol

4. Have student report to clinic before school tomorrow for a follow-up exam


CONCUSSION MANAGEMENT TEAM


PARTICIPATING PROVIDERS

Because your child is suspected to have a concussion, he or she is required to see a physician of your

choosing. The following physicians are familiar with the concussion management protocol that has been

designated by College Station Independent School District. It is advised that you see your primary care

physician or a physician familiar with CSISD protocol.

James Distefano, DO

Concussion Oversight Team Chairperson

Physicians Centre

3201 University Drive East, Suite 115

Bryan, TX 77802

Phone: (979)776-0169

Boone Barrow, MD

Concussion Oversight Team Member

Scott & White Clinic, College Station

1600 University Drive East

College Station, TX 77840

Phone: (979)691-3300

Mark English, MD


Scott & White Clinic, College Station

1600 University Drive East


Phone: (979)691-3300

Garth Morgan, MD


St. Joseph Family Medicine

4421 Highway 6 South, Suite 100


Phone: (979)690-4460

Jesse Parr, MD


University Pediatric Associates

1602 Rock Prairie Road, Suite 1100


Phone: (979)696-4440

Kim Oas, NP


St. Joseph Family Medicine

4421 Highway 6 South, Suite 100


Phone: (979)690-4470

Richard Smith, MD


Physicians Centre


Bryan, TX 77802

Phone: (979)690-4828

Kory Gill, DO

Physicians Centre


Bryan, TX 77802

Phone: (979)776-0169

Brian Goering, MD

College Station MedPlus – Barron Road

2849 Barron Road


Phone: (979)774-7587

Laura Marsh, MD

Physicians Centre


Bryan, TX 77802

Phone: (979)776-0169

Thomas Wagner, MD

Scott & White College Station Arrington Rd Clinic

1296 Arrington Road


Phone: (979)691-3636


POST-CONCUSSION MANAGEMENT GUIDE


PHYSICIAN RELEASE

Any student who is suspected of sustaining a concussion must be evaluated and released by a licensed

physician. The student must also successfully complete the return-to-play protocol and post-concussion

ImPACT or C3 Logix test as defined by the College Station ISD Concussion Oversight Team. In

addition, the athlete and parent/guardian will be required to sign return-to-play authorization forms.

CONCUSSION MANAGEMENT

The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and

then a gradual program of exertion prior to medical clearance and return to play. During the period of

recovery, while symptoms are still present, it is important to emphasize to the athlete that physical AND

cognitive rest is required. If you notice any change in behavior, vomiting, dizziness, worsening

headache, double vision or excessive drowsiness, please telephone the CSISD Athletic Trainer and

transport to the nearest hospital emergency department immediately.

PROGRESSIVE RETURN TO PLAY PROTOCOL

The return-to-play protocol following a concussion follows a progressive process as outlined herein.

With this progression, the athlete should continue to proceed to the next level if asymptomatic at the

current level. Generally, each step should take 24 hours so that an athlete would take approximately one

week to proceed through the full rehabilitation protocol once they are cleared by a physician to do so. If

any post-concussion symptoms occur while in the return-to-play program, the athlete will wait 24 hours

after the symptoms subside and then start the progression again at the beginning.

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, swimming, or stationary cycling keeping

intensity 70%MPHR; no resistance training

Increase Heart Rate

3. Sport-specific

exercise

Passing or shooting drills in basketball, running drills in

soccer; no head impact activities

Add movement

4. Non-contact

training drills

Progression to more complex training drills, eg. Passing

drills in football; may start progressive resistance training

Exercise, coordination and

cognitive load

5. Full contact

practice

Following medical clearance, participate in normal

training activities

Restore confidence and

assess functional skills by

coaching staff

6. Return to play Normal game play

NEUROCOGNITIVE TESTING

College Station ISD will be utilizing pre-season baseline testing and post-injury testing as a tool in the

concussion management protocol. The programs used to complete testing include ImPACT and C3

Logix. Every athlete is required to complete baseline testing in the assigned year prior to participation in

any athletic activities (practices or games).


CONCUSSION RETURN-TO-PLAY CONSENT


ACKNOWLEDGEMENT

The student athlete listed below has completed the College Station ISD return-to-play protocol after sustaining a

concussion. By signing this form, I understand the dangers associated with returning to play prematurely following

a concussion. I agree that I have provided a signed release from the treating physician authorizing my child’s return

to play. Furthermore, I certify that my son/daughter has successfully completed the CSISD return-to-play protocol,

and I give my permission for him/her to return to sports competition. In addition, I agree to comply with any

ongoing requirements in the return-to-play protocol.

INFORMATION DISCLOSURE

The Family Educational Right to Privacy Act of 1974 (FERPA) is a federal law that governs the release of a

student’s educational records, including personal identifiable information (name, address, social security number,

etc.) from those records. Medical information is considered a part of a student athlete’s educational record. Also,

the Health Insurance Portability and Accountability Act of 1996 (HIPAA) allows the disclosure of information from

treating physicians.

This authorization permits the athletic trainers and team physicians of College Station ISD to obtain and disclose

information concerning my child’s medical status, medical condition, injuries, prognosis, diagnosis, and related

personal identifiable health information to the authorized parties. This information includes injuries or illnesses

relevant to past, present, or future participation in athletics. I understand that I may revoke this authorization at any

time by providing written notification to the Head Athletic Trainer at my child’s school.

IMMUNITY PROVISION

I do herby agree to indemnify and save harmless the College Station ISD and any school representative from any

claim by any person whomsoever on account of such care and treatment of said student. Furthermore, I understand

this policy does not:

1. Waive any immunity from liability of a school district or open-enrollment charter school or of district or

charter school officers or employees;

2. Create any liability for a cause of action against a school district or open-enrollment charter school or

against district or charter school officers or employees;

3. Waive any immunity from liability under Section 74.151, Civil Practices and Remedies Code;

4. Create any liability for a member of a concussion oversight team arising from the injury or death of a

student participating in an interscholastic athletics practice or competition, based on service on the

concussion oversight team.

Athlete’s Name (print) ____________________________________________ Date ________________________

Athlete’s Signature ____________________________________________ Date of Birth _____________________

Parent/Guardian’s Name (print) ___________________________________________________________________

Parent/Guardian’s Signature ______________________________________________________________________


INFORMATION FOR TREATING PHYSICIAN


CSISD RETURN-TO-PLAY GUIDELINES

College Station ISD has developed a protocol for managing concussions in accordance to House Bill

2038, or Natasha’s Law. This policy includes a multidisciplinary approach involving athletic trainer

clearance, physician referral and clearance, and successful completion of activity progressions related to

their sport. The following is an outline of this procedure. The injured athlete must complete and

successfully pass all of these tests in order to return to sport activity after having a concussion.

1. All athletes who sustain head injuries are required to be evaluated by a physician of their

choosing. They must have a normal physical and neurological exam prior to being permitted to

progress to full activity. This includes athletes who were initially referred to an emergency

department.

2. The student will be monitored daily at school by the athletic trainer. His/her teachers will be

notified of their injury and what to expect. Education adjustments and accommodations may

need to be given according to physician recommendation and observations. Please indicate

educational adjustments on the reverse of this form.

3. The student will be given a neurocognitive test within 72 hours of the head injury. All athletes in

contact sports will have this assessment prior to their season to form a baseline. College Station

ISD utilizes the ImPACT and C3 Logix software programs for this assessment. The athlete’s

post-injury testing data must be within normal limits before he/she is released to begin

activity.

4. The student must be asymptomatic at rest and exertion.

5. Once cleared to begin activity, the student will start a progressive step-by-step process which will

advance at the rate of one step per day. The progressions are:

a. No activity until symptom free.*

b. Light aerobic exercise.

c. Sport-specific exercise.

d. Non-contact training drills.*

e. Full contact practice after physician release.*

f. Return to play.

g. Note – Athlete progression continues as long as the athlete is asymptomatic at

current activity level. If the athlete experiences any post concussion symptoms,

he/she will wait 24 hours after the symptoms resolve and start the progression again

at the beginning.

6. Upon completion of the return-to-play protocol, the physician of record must provide a

written statement that in the physician’s professional judgment it is safe for the athlete to

return to unrestricted participation.

*PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR THE PHYSICIAN RELEASE THAT

MUST BE ON FILE PRIOR TO ATHLETE BEING RELEASED FOR THE NEXT STAGE OF THE

PROGRESSION.


INFORMATION FOR TREATING PHYSICIAN


PHYSICIAN CONCUSSION REFERRAL FORM

Name: ____________________ Date: _______ Grade: ________ Sport/Activity: ___________________

Please see attachment for symptoms and results of neurocognitive testing.

Please provide the following information so this individual may be treated according to your instructions.

I have evaluated this athlete and it is my professional judgment that he/she:

___has a concussion* (see below) ___does not have a concussion and may begin return-to-play protocol.

___has an alternate diagnosis of __________________________________________________________

and ___ may return to play ____with, ___ without restrictions: _______________________________

*CONCUSSION MANAGEMENT PROTOCOL

The student-athlete WILL NOT be allowed to return to any activity or begin the return-to-play protocol

until evaluated by a physician skilled in management of concussions.

Student-Athletes evaluated in an emergency room CANNOT be released to begin return-to-play protocol

by the ER physician.

Please check the statement that applies to the athlete in the current state.

In my professional judgment, the

___ athlete remains symptomatic and needs re-evaluation in ____ days/weeks.

___ athlete is asymptomatic AND may begin the return to play protocol as of : ________ (date)

___ athlete is asymptomatic AND has COMPLETED the return to play protocol and may resume normal

athletic activity.

Please select all appropriate education adjustments that apply at this time

___ frequent rest or breaks in health center during the school day

___ some students may need to be driven to school and avoid walking

___ workload and homework reduction

___ extra time or postponement of tests and quizzes

___ reduction of time spent on computer, reading or writing

___ other__________________________________________________________________________

Printed name of physician/stamp: ___________________

Signature of physician: ____________________________

Please return this referral sheet with the student, by fax, or email.

College Station High School

Chelsea Frashure, ATC LAT Sam Goodey, ATC, LAT 979-731-6786 (Office)

979-731-6777(Fax)

[email protected]

A&M Consolidated High School Karl Kapchinski, ATC, LATSamantha Gonzales, ATC, LAT 979-764-5536 (Office) 979-764-5494(Fax) [email protected] [email protected] [email protected]

Concussion Management Protocol Return to Play Form

This form must be completed and submitted to the athletic trainer or other person (who is not a coach) responsible for compliance with the Return to Play protocol established by the school district Concussion Oversight Team, as determined by the superintendent or their designee (see Section 38.157 (c) of the Texas Education Code).

Please Check

Student Name (Please Print) School Name (Please Print)

The student has been evaluated by a treating physician selected by the student, their parent or other person with legal authority to make medical decisions for the student.

The student has completed the Return to Play protocol established by the school district Concussion Oversight Team.

The school has received a written statement from the treating physician indicating, that in the physician’s professional judgment, it is safe for the student to return to play.

Please Check

School Individual Signature Date

School Individual Name (Please Print)

Parent/Responsible Decision-Maker Signature Date

Parent/Responsible Decision-Maker Name (Please Print)

Designated school district official verifies:

Has been informed concerning and consents to the student participating in returning to play in accordance with the return to play protocol established by the Concussion Oversight Team.

Understands the risks associated with the student returning to play and will comply with any ongoing requirements in the return to play protocol.

Consents to the disclosure to appropriate persons, consistent with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191), of the treating physician’s written statement under Subdivision (3) and, if any, the return to play recommendations of the treating physician.

Understands the immunity provisions under Section 38.159 of the Texas Education Code.

Parent, or other person with legal authority to make medical decisions for the student signs and certifies that he/she:


POST-CONCUSSION CHECKLIST


POST-CONCUSSION CHECKLIST

This checklist will be completed by the Athletic Trainer and kept on file with College Station ISD.

STEP DATE COMPLETED SIGNATURE REQUIRED

Athlete Removed from Activity

Neurocognitive testing within 72 hours

post-injury

Parent Information packet received

Initial Doctor’s visit – Dr. note

returned to athletic trainer

Athlete is symptom-free for 24 hours –

no exertional activity

Athlete cleared by physician to start

protocol – documentation received

Light aerobic activity – 5-10 minutes on

exercise bike, or light jog; no weight

lifting, resistance training, or any other

exercise.

Moderate aerobic activity – 15-20

minutes of running at moderate intensity

in the gym or on the field without a

helmet or other equipment

Non-contact training drills in full

uniform. May begin weight lifting,

resistance training, and other exercises.

Full-contact practice or training

Concussion Return to Play Consent

returned to athletic trainer with

parent signatures

Written release from physician

received by athletic trainer.

Full game play

College Station Independent School District · Richard Smith, MD Concussion Oversight Team Member...

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