Concussion Management Policy

Reviewed: July2021

The University of Montana, Department of Intercollegiate Athletics (UMIA) is committed to ensuring the health and safety of its student-athletes. To this end, and in accordance with the NCAA Concussion Management Protocol, and the Arrington Settlement Agreement, UMIA will adopt the following Concussion Management Plan (CMP). This plan will set forth how student-athletes exhibiting signs and symptoms of concussion and student-athletes diagnosed with a concussion will be managed.

A concussion is a potentially serious injury to the brain. Most concussions do not involve a loss of consciousness. Symptoms of concussion include, but are not limited to dizziness, headache, feeling “out of it” or “foggy”, vision changes, sensitivity to light or noise, balance problems and other symptoms. UM Student-athletes, coaches, staff and administrators, are obligated to report any signs or concerns of possible concussion to the University of Montana athletic trainers and/or team physician. Concussions frequently occur in sport and repetitive concussions have been related to long term changes in brain function. The University of Montana is committed to student-athlete health and safety and the components of the University of Montana CMP are listed below.

POLICY STATEMENT: This policy ensures and communicates complete and comprehensive procedures for the management of a student-athlete (SA) who may have sustained a concussion.

PURPOSE: To provide and communicate to UMIA staff with regards to each individual’s responsibility related to the management of a student-athlete who may have sustained a concussion.

ENTITIES TO WHOM THIS POLICY APPLIES: University of Montana Intercollegiate Athletics (UMIA) Administrators, Coaches (Sport and Strength), Staff, and Rhinehart Athletic Training Staff including Physicians, Certified Athletic Trainers and Athletic Training Students.

PROCEDURE:

1) All University of Montana student-athletes are required to sign a statement annually in which the student-athlete accepts the responsibility for reporting their injuries and illnesses to the institutional medical staff, including the signs and symptoms of concussions. During the review and signing process the student-athletes will be presented with the NCAA Concussion Fact Sheet for Student-Athletes. (Appendix A) 2) All UMIA Department administrators, coaches, and athletic training staff are required to sign a statement in which they accept the responsibility for reporting signs and symptoms of concussions. During the review and signing process they will be presented with the NCAA Concussion Fact Sheet. (Appendix B) a. The head athletic trainer will work with Compliance to coordinate the distribution of informative material, educational sessions, signing, and collection of the necessary documents. The signed documents from the SA will be kept in the student-athlete’s medical file. The signed documents from the coaches and staff will be kept by the compliance staff. b. The Head athletic trainer and compliance staff will coordinate the signing of the aforementioned documents on an annual basis. c. A copy of the CMP will also be distributed through the (UMIA) Policies and Procedures manuals and the SA Handbook. d. The head athletic trainer and team physician will review and update the Concussion Policy on a regular basis. 3) Rhinehart Athletic Training Center (RATC) will have on file and posted electronically an annually updated emergency action plan for each athletics venue.

4) UMIA healthcare professionals are empowered to have unchallengeable authority to determine management and return-to-play of any ill or injured student-athlete, as he or she deems appropriate. For example, a countable coach should not serve as the primary supervisor for an athletics healthcare provider nor should they have sole hiring or firing authority over that provider. 5) The Rhinehart ATC has on file a written, team physician-directed concussion management plan that specifically outlines the roles of athletics healthcare staff (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neuropsychologist). 6) The Rhinehart ATC will document the incident, evaluation, continued management, and clearance of the student-athlete with a concussion. 7) As required by NCAA rule, and via a platform provided by the NCAA, all sport-related concussions and their resolutions will be reported to the NCAA. 8) All sports have rules in place designed to protect the SA. Even with current sports rules in place; athletics staff, student-athletes and officials should continue to emphasize that purposeful or flagrant head or neck contact in any sport should not be permitted and current rules of play should be strictly enforced.

Concussion Management Plan Baseline Testing

1) The Athletic Training staff will record a baseline assessment for all student-athletes prior to their first practice. The same assessment tools will be used post-injury at appropriate time intervals. The Baseline assessment may include the following: a. Symptom Checklist b. SCAT 5 form c. IMPACT 2) If a student athlete sustains a concussion, they will meet with a team physician prior to the start of the next season to determine if they have any ongoing issues or symptoms related to their head injury. 3) The team physician will refer the student athlete for further treatment as necessary at any point during the care of the athlete.

Concussion Assessment

When a student-athlete shows any signs, symptoms or behaviors consistent with a concussion, the athlete shall be removed from practice or competition and evaluated by a University of Montana Athletics trainer or physician on duty. NO athlete suspected of having a concussion is permitted to return to play while symptomatic! 1) UM Athletics healthcare professionals will practice within the standards as established for their professional practice (e.g., physician, certified athletic trainer, nurse practitioner, physician assistant, neurologist, and neuropsychologist). 2) Medical personnel with training in the diagnosis, treatment and management of acute concussion will be present at all practices and competitions (home and away) for basketball, football, soccer and track/field. 3) A student-athlete suspected of sustaining a concussion will be evaluated by UM athletic healthcare professionals using a clinical evaluation as well as the Sport Concussion Assessment Tool (SCAT5). Should the team physician not be present, the ATC will notify the team physician ASAP to develop a specific evaluation and treatment plan. The presence or absence of symptoms will dictate the inclusion of additional neurocognitive and balance testing. 4) Student athletes that demonstrate a Glasgow coma scale < 13, prolonged loss of consciousness, focal neurological deficit, repetitive emesis, worsening mental status or

other neurological symptoms, or spine injury shall be transported to the nearest emergency medical center as directed by the emergency action plan. 5) Student athletes will also be evaluated for cervical spine trauma, skull fractures and intracranial bleed when warranted by injury history or signs and symptoms. 6) A student-athlete diagnosed with a concussion shall be withheld from competition, practice, lifting, and class and will not return to activity for the remainder of that day. 7) The student-athlete shall receive serial monitoring for deterioration. Athletes shall be provided with the “Concussion Injury Advice” sheet located on the SCAT5 upon discharge; preferably with a roommate, guardian, or someone that can follow the instructions. 8) The student-athlete shall be evaluated by a team physician as outlined within the concussion management plan. Once asymptomatic and post-exertion assessments are within normal baseline limits, return to play will follow a medically supervised stepwise process. 9) Final clearance for return to play will be given by a physician-preferably the UM team physician.

RECOVERY and RETURN TO PLAY

Once it has been determined that a student athlete (SA) has suffered a concussion they will enter the University of Montana concussion guidelines for recovery and return to play. It is important to recognize that each concussion is different and each student athlete is different. Therefore, each case is different and will be managed by University of Montana athletics health care professionals under the direction of the Team Physician as it relates to each individual SA’s academic schedule, sport and injury. (Appendix D)

1) A student-athlete diagnosed with a concussion shall be withheld from competition, practice, lifting, and class and will not return to activity for the remainder of that day. 2) At the time of injury, a clinical evaluation is performed, symptoms checklist and SCAT5 conducted and Team Physician notified. 3) After the initial clinical evaluation, the symptom checklist should be repeated followed by referral to the team physician if indicated. 3) First day post injury, the student-athlete will have a follow up clinical evaluation and symptom checklist completed. The SA will be in the concussion protocol (see Appendix D). Also, the academic coordinator for the SA’s sport will be informed. The academic coordinator will send a communication to the SA’s instructors (see Appendix C). 4) Follow-up clinical evaluations and/or symptom checklists are completed daily until the athlete is asymptomatic and has completed the UM concussion protocol (Appendix D). 5) Student-athletes with prolonged recovery will be evaluated or referred by the team physician for potential additional diagnosis and best management options.

6) Final determination of return-to-play and return-to-learn are made by the team physician.

7) All documentation pertaining to the student-athlete’s concussion assessment will be included in the student-athletes medical record.

RETURN TO LEARN

University of Montana Athletic healthcare professionals will work diligently to educate coaches, academic staff, and athletes on the importance of a safe return to the classroom for any concussed athlete. Certain activities that take place in the classroom may exacerbate an athlete’s symptoms, which could ultimately lead to a delayed recovery and/or return to play. Returning to academics after a concussion is a parallel concept to returning to play after a concussion. After a concussion, brain energy may not be sufficient to perform normal cognitive exertion and function. The following RTL guidelines will be followed for a SA diagnosed with a concussion.

1) Once a SA has been diagnosed with a concussion he/she will be advised not to attend any class or do any class/mental activity on the same day. They will be advised not to study, read or do any class preparation. Mental rest. 2) The ATC working with the SA will notify the sport athletic academic coordinator about the injury and restrictions. The sport athletic academic coordinator will then send an email to each of the student’s instructors that the SA will not be at class and will likely need modification to assignments, quizzes, and test for a period of time. (Appendix C) 3) If the SA cannot tolerate light cognitive activity, he or she should remain at home or in the residence hall as directed by the team physician or physician’s designee. The SA will be checked on regularly. 4) Once the SA can tolerate cognitive activity without return of symptoms, he/she should return to the classroom/studying as tolerated. At any point, if the SA becomes symptomatic, or scores on clinical or academic measures decline, the staff athletic trainer and/or team physician should be notified and the SA’s cognitive activity reassessed by the team physician. 5) The return to learn (RTL) concept should follow an individualized and step-wise process directed by a multidisciplinary team and should be individualized to the injured SA. The athletic academic coordinator for the applicable sport of the injured student athlete will be the point person for return to learn and will be in constant communication with the Health care team. A multidisciplinary team may include: team physician, athletic trainer, psychologist, faculty athletic representative, athletic academic counselor, course instructor, athletic administrator, coaches and possibly the campus learning specialists, and/or office of disability services for students.

The level of multi-disciplinary involvement should be made on a case-by-case basis. 6) Modifications to the SA’s schedule/accommodations may need to be made for up to 2 weeks as indicated, and will be made and followed by the athletic academic advisor and the SA. 7) Cases that cannot be managed through schedule modification/academic accommodations should utilize campus resources within the UM office of disability services for students and that are compliant with ADAAA. Athletic academic services will help the SA with this transition.

REDUCING HEAD TRAUMA IN SPORTS

The University of Montana is committed to reducing exposure to head trauma in sports.

1. Management of head trauma will always take a safety first approach. 2. UM Intercollegiate athletics compliance will ensure appropriate measures are followed with in year round football practice contact guidelines. 3. The UM athletics health care professionals will ensure that concussion will be managed following up to date and independent medical care guidelines. 4. The UM athletic health care professionals will educate athletes and coaches on the importance of taking the head out of the game and appropriate care of head injuries. 5. UM athletics administration and athletic healthcare professionals will stress the importance of teaching proper techniques and reducing gratuitous contact during practice to coaches and those who make practice plans.

Appendix A University of Montana Student-Athlete Concussion Injury and Illness Agreement to Self-Report

Concussion: o Concussion symptoms can range from mild to severe, and may present differently in each student-athlete, but are all important to report. o A concussion is a traumatic brain injury that is caused by a blow to the head or body, and results in an alteration in mental status, with or without loss of consciousness. o Symptoms of concussion may include: amnesia/loss of memory, confusion, headache, loss of consciousness, balance problems or dizziness, double or fuzzy vision, sensitivity to light or noise, nausea, feeling sluggish or groggy, feeling irritable, concentration or memory problems, and slowed reaction time.

Reporting Concussion: o A student athlete who exhibits signs or symptoms of a possible concussion shall be removed from practice or competition and assessed by a certified athletic trainer and/or Team Physician of the University of Montana. o A student athlete who has suffered a concussion may not return to practice or competition on the day of injury, and until symptoms have resolved. Medical clearance to return to activities can only be given by the team physician. o The University of Montana staff may not be able to fully evaluate and give appropriate care for a student athlete who may have suffered a concussion or any other type of injury or illness, unless the student athlete discloses any and all of his or her symptoms to the certified athletic trainer. o Serious and/or permanent harm may result if a student athlete fails to inform the athletic training staff about the signs and/or symptoms of their injury or illness (concussion or other issues).

By signing below I acknowledge that I have read and understand the above information and I accept responsibility for reporting all injuries and illnesses, including symptoms of concussions, to the athletic training staff. I have also been given the NCAA concussion fact sheet.

_______________________________________ Name (Print) ___________________ Sport

_______________________________________ Student-Athlete’s Signature ___________________ Date

______________________________________ ___________________ Parent/Guardian Signature (if under 18 years of age) Date

Appendix B University of Montana COACHES Concussion Injury Agreement to Report

Concussion: o Concussion symptoms can range from mild to severe, and may present differently in each student-athlete, but are all important to report. o A concussion is a traumatic brain injury that is caused by a blow to the head or body, and results in an alteration in mental status, with or without loss of consciousness. o Symptoms of concussion may include: amnesia/loss of memory, confusion, headache, loss of consciousness, balance problems or dizziness, double or fuzzy vision, sensitivity to light or noise, nausea, feeling sluggish or groggy, feeling irritable, concentration or memory problems, and slowed reaction time. o A repeat concussion that occurs before the brain recovers from the previous one can slow recovery or increase the likelihood of having long-term problems. In rare cases, repeat concussions can result in brain swelling, permanent brain damage and even death.

Reporting Concussion: o A student athlete who exhibits signs or symptoms of a possible concussion shall be removed from practice or competition and assessed by a certified athletic trainer and/or Team Physician of the University of Montana. o A student athlete who has suffered a concussion may not return to practice or competition on the day of injury, and until symptoms have resolved. Medical clearance to return to activities can only be given by the team physician. o Serious and/or permanent harm may result if a coach fails to inform the athletic training staff about the signs and/or symptoms of their injury or illness (concussion or other issues).

By signing below I acknowledge that I have read and understand the above information and I accept responsibility for reporting all injuries and illnesses, including symptoms of concussions, to the athletic training staff. I have also been given the NCAA concussion fact sheet for coaches.

_______________________________________ Coach’s Name (Print) ___________________ Sport

_______________________________________ Coach’s Signature ___________________ Date

Appendix C ATHLETIC ACADEMIC SERVICES UNIVERSITY OF MONTANA MISSOULA 406.243.2600 MEMORANDUM

CONFIDENTIAL STUDENT INFORMATION

DATE:

TO:

FROM: Name, Athletic Academic Services Name, Team Physician, Curry Health Center, Athletic Training Staff, Rhinehart Athletic Training Center

RE: Minor Traumatic Brain Injury (MTBI) to a Student-Athlete:

Student –Athlete name has sustained a concussion or minor traumatic brain injury. National standards recognized by health care providers who deal with MTBI patients consider the standard of care for this injury as physical and mental rest. Mental rest means no TV, no loud noises, no texting, no computer work or games, and no classes, quizzes, or tests. Physical rest means no increase in heart rate (no workouts or practice). In many cases people recover from this injury in a timely manner. Research has shown that one of the main factors in a quick recovery is initially taking enough time for physical and mental rest.

The student-athlete above is being monitored by health care professionals on a daily basis and adjustments in physical and mental activity will be made based on their symptoms. The student-athlete and the athletic academic coordinator will be in contact with you to help with any class modifications that may be appropriate for continued academic success while recovering from this injury. Please, feel free to contact Athletic Academic Services at 2432600 with any concerns or questions that you may have. Your understanding in this matter is greatly appreciated.

Appendix D RHINEHART ATHLETIC TRAINING CENTER THE UNIVERSITY OF MONTANA CONCUSSION GUIDELINES

Adapted from Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in sport held in Zurich, November 2008

Concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include: 1.Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an "impulsive" force transmitted to the head/brain. 2.Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. 3.Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury. 4.Concussion results in a set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course; however it is important to note that in a small percentage of cases, post-concussive symptoms may be prolonged. 5.No abnormality on standard structural neuroimaging studies is seen in concussion.

GUIDELINES FOR RECOVERY & RETURN TO PLAY

Rehabilitation stage 1.Remove from practice or play

*DOI

2.No Activity

*Date

3.Light Aerobic exercises

*Date

4. Sport Specific exercises

*Date

Functional exercises at each stage Objective of each stage

Any student athlete (SA) who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or play for 24 hours. SA will be monitored for deterioration of signs, symptoms or behaviors. Follow proper Emergency Protocol. When in doubt sit them out. Use an IMPACT card if unsure in determining concussion. SCAT -5 once back to RATC.

Complete physical and cognitive rest. See a medical professional Recovery (no academic work, video games, text messaging or activities that require concentration). ATC to notify Athletic Academic Services.

Return to school. Walking or stationary bike keeping intensity <70% max predicted heart rate. No resistance training. Take Impact. If athlete can return to school with no return of symptoms, then the athlete can increase heart rate. If still no return of symptoms, then take Impact.

Running, jogging. No head impact activities. Add movement. Begin balance rehabilitation.

5. Non-contact training drills

*Date

6. Full contact practice

*Date

7. Return to play

*Date Progression to more complex training drills, eg. passing drills in football and soccer, shooting in basketball. May start progressive resistance training. Exercise, coordination, and cognitive load

Following physician clearance participate in normal training activities. Restore confidence and assess functional skills by athletic trainer and coaching staff. IMPACT test again to show normalcy.

Normal game play

With this stepwise 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 asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, the patient should stop whatever activity they are doing, wait until they are again asymptomatic for at least 24 hours, and then drop back to the previous step in which they were able to successfully complete while asymptomatic, and try to progress again. *DOI (date of injury) should be recorded and each level dated and signed by MP when completed. Finally the date of return should be recorded and sheet placed in athletes file. **Asymptomatic: No headache, dizziness, or impaired orientation, concentration, or memory dysfunction during rest or exertion. Things to consider during above stages while asymptomatic: 1) Maintain improving IMPACT score and 2) Level of Medication(s).

MODIFYING FACTORS IN CONCUSSION MANAGEMENT

Factor Modifier

Explanation

Symptoms Number - severity - duration (>10 days) Increases in symptoms will increase the time to recover. If student athlete takes longer than 3 weeks to return to activity refer to neuropsychologist.

Signs Prolonged loss of consciousness ( >1 min), amnesia LOC and Post-traumatic* or Retrograde Amnesia** may be indicative of a more severe traumatic brain injury. Further evaluation may be needed.

Sequella Concussive convulsions May require further evaluation and treatment. (5.3)

Temporal Frequency - repeated concussion over time Timing - injuries close together in time “Recency”- recent concussion or traumatic brain injury Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each successive concussion Athletes with increase sensitivities need more conservative treatment

Age Child and adolescent (<18)

Co- and Premorbidities

Migraine, depression, or other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, sleep disorders Athletes with history related to the brain create different issues when dealing with brain trauma. (5.4)

Medication Psychoactive drugs, anticoagulants

Behavior Dangerous style of play

Sport High risk activity, contact and collision sport, high sporting level *Post-traumatic Amnesia: No or fleeting memory of events following the injury. **Retrograde Amnesia: No or fleeting memory of events preceding the injury.

All student-athletes have signed the following:

AGREEMENT TO DISCLOSE INJURIES AND ILLNESSES

In consideration of my being permitted to participate in the intercollegiate athletic program(s) at The University of Montana, I agree to fully disclose to the Athletic Medicine staff, health services staff, team physicians, and/or medical consultants engaged by them, any and all signs and symptoms of injury and/or illness, including concussions/mild traumatic brain injury about which I become aware. I understand that any disclosed information will be utilized for the purpose of safeguarding my health as it pertains to my participation in intercollegiate athletics at The University of Montana. I also understand that any disclosed information will be treated as confidential health care information and will only be shared with those directly involved in decisions related to my participation in UM athletics. I also verify that I have been given information pertaining to the signs/symptoms, prevention, and care of concussions/mild traumatic brain injury, and I may request a copy of UM Athletics concussion protocol, which is also available in the RATC for my reference.

All coaches have been given the NCAA Concussion: a fact sheet for coaches. There are NCAA Concussion: a fact sheet for student-athletes and concussion information sheets posted in all locker rooms.

Sources:Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. British Journal Sports Medicine 2013:47:250-258. NCAA concussion management plan: http://www.ncaa.org/ Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal Sports Medicine 2009:43:76-84. http://www.nata.org/jat/readers/archives/44.4/attr-44-04-434.pdf or http://bjsm.bmj.com/cgi/content/full/43/Suppl_1/i76 Practice Parameter: The Management of Concussion in Sports; American Academy of Neurology; 1997,48:581-585. Cerebral Concussion in Sports: Management and Prevention; Sports Medicine 14 (1): 64-74, 1992. Robert Cantu

More conservative treatment is recommended for the young and for those whose brain is still developing. Research has shown that these athletes take longer to recover and suffer more severe injury with less trauma. (6.1)