college station independent school district · richard smith, md concussion oversight team member...
TRANSCRIPT
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.
COLLEGE STATION ISD SPORTS MEDICINE
INFORMATION FOR PARENT/GUARDIAN
College Station ISD - 2014
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
COLLEGE STATION ISD SPORTS MEDICINE
CONCUSSION MANAGEMENT TEAM
College Station ISD - 2014
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
Concussion Oversight Team Member
Scott & White Clinic, College Station
1600 University Drive East
College Station, TX 77840
Phone: (979)691-3300
Garth Morgan, MD
Concussion Oversight Team Member
St. Joseph Family Medicine
4421 Highway 6 South, Suite 100
College Station, TX 77845
Phone: (979)690-4460
Jesse Parr, MD
Concussion Oversight Team Member
University Pediatric Associates
1602 Rock Prairie Road, Suite 1100
College Station, TX 77845
Phone: (979)696-4440
Kim Oas, NP
Concussion Oversight Team Member
St. Joseph Family Medicine
4421 Highway 6 South, Suite 100
College Station, TX 77845
Phone: (979)690-4470
Richard Smith, MD
Concussion Oversight Team Member
Physicians Centre
3201 University Drive East, Suite 425
Bryan, TX 77802
Phone: (979)690-4828
Kory Gill, DO
Physicians Centre
3201 University Drive East, Suite 115
Bryan, TX 77802
Phone: (979)776-0169
Brian Goering, MD
College Station MedPlus – Barron Road
2849 Barron Road
College Station, TX 77845
Phone: (979)774-7587
Laura Marsh, MD
Physicians Centre
3201 University Drive East, Suite 115
Bryan, TX 77802
Phone: (979)776-0169
Thomas Wagner, MD
Scott & White College Station Arrington Rd Clinic
1296 Arrington Road
College Station, TX 77845
Phone: (979)691-3636
COLLEGE STATION ISD SPORTS MEDICINE
POST-CONCUSSION MANAGEMENT GUIDE
College Station ISD - 2014
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).
COLLEGE STATION ISD SPORTS MEDICINE
CONCUSSION RETURN-TO-PLAY CONSENT
College Station ISD - 2014
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 ______________________________________________________________________
COLLEGE STATION ISD SPORTS MEDICINE
INFORMATION FOR TREATING PHYSICIAN
College Station ISD - 2014
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.
COLLEGE STATION ISD SPORTS MEDICINE
INFORMATION FOR TREATING PHYSICIAN
College Station ISD - 2014
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)
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:
COLLEGE STATION ISD SPORTS MEDICINE
POST-CONCUSSION CHECKLIST
College Station ISD - 2014
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