There are a number of obvious reasons why more and more Provincial and State governments are introducing legislation requiring school boards to develop a formal concussion management policy for their schools. It is imperative for school boards to change the way concussions have been treated in the past in order to ensure the well-being and safety of student-athletes. School Boards and post-secondary institutions are also going to have to demonstrate in a very specific, concrete manner that they are complying with some universally accepted principles when it comes to risk management in this area. As it stands now, most jurisdictions have very general protocols with respect to concussion management. The provincial and state governing bodies are therefore taking steps to make sure that school boards and post-secondary institutions have formal policies in place that will enable them to meet their legal and legislative responsibilities with respect to concussion management programs covering their student-athletes.

Legal Review of Local Program Recommended

Regardless of what kind of protocols a school board or post-secondary institution adopts, it is strongly recommended that legal counsel be asked to review the program and provide an opinion as to the risk of liability and perhaps offer suggestions on what should be done to further reduce any risk.

A Very Serious Injury That May Not Have Been Properly Treated In The Past

Medical and scientific researchers from around the world are coming up with clear and undisputable evidence that a concussion is a very serious brain injury that has for the most part not been treated as effectively as it could have been in the past. This realization is coming to light because of the tremendous advances in technology that are now allowing us to study the effects of brain trauma much more closely. Concussion-like symptoms that are still present in older adults are being linked to multiple concussions that were received from sport-related injuries suffered when they were very young. And in many cases, it is felt that failing to take sufficient time to allow for the damage from earlier injuries to heal properly may have resulted in life-altering consequences which changed the entire direction of their life.

Participation In Competitive Sports Is Growing Rapidly

During the past several decades we have also witnessed an incredible growth in the number of people of all ages participating in competitive sports activities at the amateur, recreational and professional levels. As well, the growth of minor sports has created tremendous opportunities for children to take part in competition at all levels all year long. This is a testament to the success of decades of major promotional initiatives designed to encourage more people to participate in sports. The result is that children are entering organized sports at a very young age and are playing many more games and practices than they ever have. It is not unusual for a hockey season to begin in August and finish up the following April with players taking part in well over one hundred games and practices. Children are also encouraged to participate on competitive teams which play more games and are much more intense. This is not just for hockey but sports such as football, basketball and soccer as well. There is really no “off-season” for student-athletes so it is hard for the brain to recover from repeat concussions or sub-concussions. The damage may not be sufficient to produce signs, symptoms or behaviours consistent with concussion, but researchers are coming up with evidence that may eventually prove that concussions are more likely to be caused by a series of sub-concussive damage accumulating over time, thus rendering the brain more vulnerable and less able to cope with trauma.

School Boards Are Under Pressure To Provide More Sports Options For Students

School boards are also under pressure to increase the amount and variety of sporting activities available to their students in order to promote and motivate a lifestyle consistent with personal healthy living and fitness. School sports are thus experiencing unprecedented growth, especially as many parents see the advantages of their children taking part in sporting activities where there is a balance between athletics and academics. Community organizations will continue to thrive, but there is a growing trend towards secondary school students choosing to play for their school rather than for their local sports association. And in order to provide an attractive alternative to student-athletes who might otherwise continue to play on their community teams, schools are increasing the number of games, tournaments and practices so that student-athletes end up playing almost as many games for their school team as they would on a community club.

Over 50% of Student-Athletes Will Receive At Least One Concussion By The End of High School

Because of the increase in participation, intensity, training and competitiveness of both community and school sports, it is not surprising to hear reports of as many as 50% of all student-athletes receiving at least one sport-related concussion before they leave high school. Many experts feel that this is a conservative estimate. Imagine the concern parents would have if they were told that over 50% of student athletes would break at least one leg before they leave high school? Or would need a knee operation before the end of high school? It is likely that there would be a great deal more attention to safety if that were the case. Unfortunately, since concussions often go unreported, many student-athletes go through their entire high school years thinking they were concussion-free, when in fact they may have had their life altered as a result of brain trauma that was not treated properly.

School Boards Are Being Given A Great Deal of Leeway

The storm of media attention that has risen during the past few years about the dangers of returning to play too soon after suffering a concussion is starting to frighten government leaders who are responding by introducing legislation ordering school boards to do something to protect our student-athletes. One of the challenges for school boards is that they are being told that they must have a concussion management policy, but they are not being given much direction on the specifics. Things are pretty wide-open to interpretation so we don’t think much has been done other than to create anxiety among parents who are now beginning to wonder if they should even allow their children to participate in certain contact sports.

What must be kept in mind is that school boards are always held to a higher standard when it comes to the care and well-being of the children attending the schools operated by the board. For example, advances that are being made in sports medicine research will soon force physicians to update and modify their outdated sports medicine guidelines with respect to the treatment of student-athletes who display signs, symptoms or behaviours consistent with concussion. The guidelines and practices will need to be more consistent with what the law expects of them in light of those advances in research.

Experts in this field are certain that at some point in the near future researchers will establish an evidence-based medical guideline for making return-to-play decisions for athletes after concussion in order for physicians and athletic trainers to be more informed about the standards that will be expected of them in law. The test will be what lay jurors feel would constitute reasonable conduct by a practitioner. Outdated procedures and practices will not be recognized as a defence for people in the medical field who are generally held to a higher standard.

This expectation of a higher standard will also be applied to schools. Therefore, despite the minimum requirements outlined in legislation, schools will be expected to follow a much higher standard when it comes to the treatment of concussions. One thing we should always keep in mind is that when legislation is passed outlining minimum requirements for school boards, this legislation is a result of what was politically capable of being accepted by the majority of politicians who voted on the bill. After hours of debate and committee study, what is left on paper in the legislature is usually a much watered-down version of what experts would like to see in order for “something” to be passed into law. A political standard may not be sufficient in light of modern research which may tell us that schools should adopt a much higher standard.

SERIOUS IMPLICATIONS FOR ADOLESCENTS

What is going to make this process extremely difficult for law makers and school board administrators is that researchers are presenting conflicting points of view when it comes to concussions that occur in younger children, adolescents and young adults.

The good thing is that concussions are now being acknowledged as a brain injury that actually changes the way the brain functions. The more we find out about how the brain works, the more we realize how little we’ve known about the brain. However, this new knowledge is allowing us to better understand what we must do to protect against repeat concussions.

It is pretty evident that injured student-athletes who are given enough time to rest, both cognitively and physically, recover twice as quickly as those who are returned too soon. It is also being proven that student-athletes who do not wait until their original injury has had time to heal may suffer from post-concussion symptoms for up to a year or more and actually may have their personal developmental trajectory altered due to the significant physical, emotional and cognitive stress that is caused by the injury and subsequent injuries.

Unfortunately, the absence of concussion symptoms doesn’t necessarily mean the brain has fully recovered, so it is extremely difficult to determine when the healing process is complete and it is safe to return to normal levels of activity. To make it even more confusing, there are now two schools of thought emerging on the impact of concussions on young brains and both have valid arguments.

ON THE ONE HAND…

First of all, research has found that teenagers who suffer sports-related brain trauma have more widespread injury and prolonged brain swelling than adults. This may be related to the fact that the developing brain in a teenager has double the number of neural connections than that of an adult, so an injury will impact a much larger region of the brain because of this interconnectivity.

We also know that the immature brain is approximately 60 times more sensitive to the chemical substances that are produced following an injury. And since an injury to the brain creates a massive power surge of electrical energy that produces a cavalcade of chemicals released into the brain in areas where the chemicals may not normally be found, this increased sensitivity may very well have serious consequences on a young adolescent brain. Especially since the number of synaptic connections in a teenage brain is double that of an adult, thus allowing for the release of a much greater amount of chemicals during one of these “power surges”.

Because of the increased sensitivity to the chemical changes following an injury, coupled with the inadequate blood flow to help with the repair process, complete physical and mental rest is absolutely critical to prevent further damage. Therefore, many experts feel that high-school athletes might well be expected to have a slower recovery than older adults and to be more susceptible to severe neurological deficits should they be re-injured during recovery.

This is why we recommend that a school board Student-Athlete Concussion Management Program emphasize the importance of being completely satisfied that all signs, symptoms and behaviours consistent with concussion have been resolved before beginning to return to physical activity. It is also why we recommend that a partnership approach be taken, involving not only a medical health practitioner, but also the parents/guardians, the classroom teachers, the school coaches, a neuropsychologist and the student-athlete him/herself. Everyone associated with the student-athlete must be involved in observing for lingering signs, symptoms and behaviours consistent with concussion before the School Principal, who is ultimately the one responsible for the well-being of the students at his/her school, feels confident enough to allow a concussed student-athlete to return to competition.

This is a point that we will mention time and time again because the symptoms of a concussion will usually disappear well in advance of complete healing. For example, the part of the brain that is injured may cause headaches as a symptom. As the healing process is taking place, the damaged area may stop producing headaches because the stress is reduced. This does not mean that the injury has healed. It just means that it has either healed enough to stop the pain or the student-athlete is at rest so that the particular neurons are not being called upon to do any work. If there is no electrical activity going on in that area of the brain, then there won’t be any symptoms. Nevertheless, just because the symptoms have disappeared, we cannot assume that the damaged area has healed. In fact it is more likely that the damaged area is still very vulnerable and susceptible to further injury. Therefore, there is great danger in assuming that just because the headache is gone the concussion has healed.

ON THE OTHER HAND…

Some experts argue that teenage student-athletes should have a greater potential for recovery after a concussion because of their greater capacity for reorganization of the neural connections in the brain compared with adults. The fact that the developing brain has double the number of neural connections of an adult means that the excess connections should allow for easier neural rerouting during the recovery period.

This means that if the usual communication pathway has been damaged or blocked because of a concussion, the brain may be more easily able to find another route to restore the communication to near normal functionality. This leads some experts to conclude that this functional plasticity may in fact mean that teenage athletes never completely recover from their original injury, but that they actually reacquire near normal functionality because of the reorganization of the communication network through new pathways that are closely related to the original. In other words, the teenage brain discovers a new way of accomplishing approximately the same results, but will never be exactly the same as before.

What is not completely understood is whether or not the reorganization and rerouting can ever accomplish the exact same results because of the widespread impact of the original injury on so many other regions of the brain. To better understand what this means, think of what happens when you are trying to draw a straight line between two points. If you are slightly off line at the beginning, by the time you get to your destination point you will have missed by a lot. The original error magnifies over time, so this is what many people think happens to the brain during recovery. The place where the original damage occurred may be repaired to a state that is “close” to normal, but by the time you proceed to the millions of neurons in the communication pathway leading from that damaged area you may end up changing the functioning of so many other parts of the brain.

Another concern is that there may be areas of the brain where reconstruction is delayed simply because they involve functions that may not be commonly drawn upon by the student-athlete. If the connections are not needed, then electricity will not require the routes, so the damage remains unresolved and eventually gets weeded out by the brain as something that is not needed. For example, the teenage brain has approximately 1000 trillion neural connections. By the time a person is in his/her late twenty’s, this has been reduced to approximately 500 trillion connections. The brain goes through a “pruning” or “decluttering” process whereby it eliminates parts of the brain that are not being used and which are not likely to be used during the person’s lifetime. If a particular area of the brain has been damaged, and if that part of the brain has been used in the past by the student-athlete, then the brain may feel that the person has decided that it no longer needs these connections if an injury has not had a chance to heal. In fact, while going through this pruning process, the brain may actually decide to eliminate the damaged areas to begin with. When doing this, the brain will usually find another connection that will allow the student-athlete to do basically the same function, but it may not be at the same level as before the injury.

This may explain some of the changes we see in behaviour or personality after a brain injury occurs in a student-athlete. The new behaviour is what is being reinforced and strengthened, replacing the old behaviour. Therefore, when a coach is beginning to rehabilitate an athlete through training that will rebuild the skills of the player, he/she must also pay attention to the motivation and reviving of attitude and passion to the game so that both areas are brought back to pre-injury levels. The change in attitude may not be noticed until the following season and may be passed off as the student-athlete just experiencing a change in personal interests, when in actual fact this may be a post-concussion symptom.

Therefore, it may be the case that student-athletes need to limit the amount of physical, emotional and cognitive stress much longer than first thought in order to give the brain time to repair the damages to the original connections to avoid the brain from rerouting or restructuring and thus preventing them from returning to pre-injury status.

Another fact to consider is that the reconfiguring that takes place in the brain during a controlled rehabilitation period may be able to "recover" most of the functionality that was impaired as a result of the injury, but the affected areas of the brain may remain weaker and vulnerable to future injury with less intense trauma. Think once again of an athlete who receives a bad ankle sprain for the first time. Even after the sprain has healed, the athlete may find that he now has a "weak ankle" and is much more easily injured, thus suffering the inconvenience of future ankle sprains from less intense trauma to the ankle. The same may be found for injuries to the brain. Once you get your first concussion, you are much more vulnerable to getting future concussions, possibly because you now have a weak area of the brain that is more easily injured from less intense trauma.

HELPING SCHOOL BOARDS MEET THEIR LEGAL RESPONSIBILITIES

All that being said, we caution that school administrators should not be too alarmed if they find that once they implement a Student-Athlete Concussion Management Program into their school, the number of athletes suffering from concussions may increase by anywhere from five to seven times. This is an indication of how many concussions go unreported without the program. Student-athletes who are under a proper Student-Athlete Concussion Management Program will not likely be able to hide their symptoms and with so many partners on the look-out for signs of concussion, it means that you will be able to provide a much higher degree of protection against serious injuries that can result from receiving a second concussion while still recovering from the first.  

Many experts indicate that there will never be a way of finding the exact number of injuries that take place, but the closer we look the more we will find. This means that as coaches, parents and student-athletes themselves are better educated on how to spot signs and symptoms of concussion, the numbers are bound to increase.

After examining legislation that has been already introduced in some areas of Canada and the United States, and taking into consideration what we feel are the universally accepted components of an effective student-athlete concussion management program, we are now going to examine some of the elements that we expect will be included in most provincial and state legislation in the years to come.

First, we would like to point out that in preparing our framework model CMP Student-Athlete Concussion Management Program we were cognizant of these expectations and have therefore recommended protocols and procedures that we feel would be compliant with the highest standards that could possibly be legislated anywhere on the continent. This means that any school board which adopts the basic elements of the CMP Program into their own concussion management policy will be able to rest assured that they should have no problem meeting the requirements of all existing or future legislation. As we work together with the school board concussion management steering committee, we will make sure to add other provisions and procedures that will address any additional requirements and we will have our legal consultant provide an opinion on any of the terms and provisions that are added.

BASIC PHILOSOPHY

The first thing we wish to point out is that just from what we already know about the nature of concussions and traumatic brain injuries, the underlying philosophy of any student-athlete concussion management program, whether it is designed for a school board, a post-secondary institution or a community sports organization must clearly demonstrate a concern for the long-term health and personal well-being of the student-athlete. The protocols and procedures must not be seen to favour getting a student-athlete back into the “game” at the risk of his/her health.

Everything we do should also be done from the point of view of “assuming the worst”. If anything, we will always try to err on the side of caution. We do not want to do anything that may have any chance of doing harm to the student-athlete. We are learning now that if we do not manage this type of injury to the brain properly, there could be serious consequences much later on in life.

Therefore, when it comes to “identifying a concussion”, we must make sure that the student-athlete concussion management program includes identification procedures that are based on the “reasonable presumption” of a concussion. In other words, all we need is a “feeling or opinion” that a concussion “may” exist as the determining factor in the identification of a concussion.

We must also clearly establish that all a person needs as evidence in forming that opinion is any of the universally accepted signs or symptoms that would lead a reasonable person to assume that a concussion may exist. In many situations the law requires a “balance of probabilities” as a measure of justice, but when it comes to concussions, we recommend that we adopt the principle of “reasonable probability”. And reasonable probability exists if there are “any” signs or symptoms, or if there is “any” suspicion that a student-athlete may have suffered a concussion. We do not require clear and conclusive proof of the existence of a concussion because in many cases, student-athletes are not even aware they have a concussion until symptoms present themselves hours or days later. So if anyone observing a student-athlete feels, based on a “reasonable presumption” that the student-athlete may have a concussion, we will take that “reasonable presumption” as our definitive identification that a concussion does indeed exist. If we adopt this principle, the chances of “missing” a concussion should be greatly reduced.

In order to determine that a concussion was not received or that a concussion no longer exists, the burden of proof must meet the test best described as “beyond a reasonable doubt”. In other words, we must present evidence that would allow a reasonable person, in this case the School Principal or Institution Athletic Director, to conclude “beyond a reasonable doubt” that the student-athlete is no longer experiencing the effects of a concussion. This pretty well means that all persons involved must declare that they are unaware of “any” signs or symptoms that would indicate a concussion. This declaration can only be made after careful observation of the student-athlete and possibly the inclusion of neuropsychological testing which would compare post-injury with baseline assessments.

To sum up, when it comes to identifying if a student-athlete has a concussion, all we need is the slightest hint of evidence or assumption from any “one” person who is observing the student-athlete. That means that any one of the coaching staff, parents/guardians, school leaders, classroom teachers, or the student-athlete him/herself has the authority to “identify” a concussion and can do so with the “slightest” bit of evidence or assumption.

However, when it comes to determining that the student-athlete has recovered from a concussion, we need “everyone” who is involved with the student-athlete to declare that there are no known symptoms or signs of concussion evident. We need “all” people signing these clearances or declarations, including the doctor, the parents/guardians, the student-athlete and the classroom teachers. We also need to know that the post-injury neuropsychological assessment is back to baseline levels. Only then, if the School Leader is satisfied “beyond a reasonable doubt” that the student-athlete has recovered, will he/she be able to give clearance for the student-athlete to return to physical training supervised by a School Coach.

If the concussion management program adopts this basic philosophy in all aspects of the program, then all people involved will feel absolutely confident that they are doing everything possible to ensure the well-being of the student-athletes in their care. We must make it extremely easy to “identify” a concussion and thus initiate the protocols and we must make it extremely difficult to determine that a full recovery has taken place. If we do this, then we will be reducing the risk of making an error that may affect the student-athlete.

DISTRIBUTION OF INFORMATION

It’s a pretty safe bet that every province and/or state will soon require school boards to accept responsibility for distributing information about the prevention, identification of symptoms, and management of concussions to school staff, coaches, parents/guardians, student-athletes and volunteers. School boards will likely have some discretion with respect to the content of the material that is to be distributed, but the challenge will be to make sure that the information is up to date, relevant and contains a consistent core message about universally accepted concepts about concussion management.

In preparation for the new legislative requirements, we recommend that school boards develop appropriate “brochures or guidance forms” for parents, teachers, principals, coaches, and student-athletes. These guide books should be available online and may also be provided in print form. Each school operated by the board should be responsible for making sure that the guide books are distributed to all partners each year so that they can be updated as new information is provided. This will ensure that parents/guardians, coaches, teachers and student-athletes are aware of the school board concussion management procedures.

We suggest that there be some sort of recording system set up so that the schools have proof that the material was at least “received” by the target groups. It is not enough to simply distribute the information. We recommend that at the very least the parent/guardians be required to sign something that indicates they have received the information and understand the content. It may be advisable to have one of the School Leaders collect this signed declaration or actually “hand out” the information package to the parents/guardians.

One of the things we recommend is a parent/guardian permission form that must be signed prior to a student-athlete participating in try-outs for a school team. The permission form contains a declaration by the parent/guardian that he/she/they have read and understood the procedures and protocols of the concussion management program and are in full agreement and in full support of the program. This gives you something on file if there is any question about the parental support later on in the season.

This means that a school board’s Student-Athlete Concussion Management Program will also have to include some sort of built-in renewal process so that the material can be reviewed and updated each year. It will also mean that the material will have to be written so that it can be understood by a wide range of age groups and demographic backgrounds. This is one of the on-going continuing education components that we will provide when a school board incorporates the CMP Program Guide into their own local program. It’s not just enough to provide the initial training. The important part is providing continuing education to keep the knowledge level current.

In developing the curriculum for the CMP framework model Student-Athlete Concussion Management Program we went to great lengths to search out the most accepted universal principles that we could find. We also made it a point to enhance basic information by going just a bit more in depth than most other models we could discover. We feel that it is going to be extremely important for a school board to feel confident that the information contained in its Program Guide is accurate and recognized by most of the top experts in the field of concussion management. Therefore, once we blend the contributions from the school board steering committee with the content of the CMP Program, we feel the school board will end up with a Student-Athlete Concussion Management Program that is as broad in scope as any in the world.

PREVENTION MEASURES

We expect that this is one area where provincial and state law makers will provide very limited direction since this is an area generating much debate and confusion. Many experts will have you believe that prevention is linked to equipment, and yet with the current budget restraints that school boards find themselves under, governments may need to inject funding to allow school boards to purchase better quality equipment. At the present time school boards must comply with acceptable standards with respect to equipment, but when it comes to marketing of products that are supposed to be able to protect against concussions, the bar is raised pretty high. We will agree that there is no way sub-standard or unsafe equipment should be allowed to be used by student-athletes in a school sponsored athletic event, and that being said, school boards will have to be very vigilant about making sure to keep track of maintenance history to prove that they are in compliance with acceptable standards.

It is our opinion, however, that personal sports equipment only goes so far towards providing protection to student-athletes and that protection is mainly against structural injuries such as a fractured skull. A concussion is a brain injury caused by the rapid acceleration, deceleration or twisting of the brain when the body experiences a severe force that also may cause the brain to strike against the bony surface of the skull. A better helmet won’t necessarily prevent a concussion. It might prevent a fractured skull, but it is unlikely to provide much in the form of protection to the brain inside the skull.

Rule changes are always being put forward for consideration, but this leads to another area that may need to be dealt with carefully and involves many different political challenges. However, we do believe that some rule changes are possible and we encourage school board administrators to push for rule changes that make sense. For example, eliminating the “kick-off return” in football would prevent many serious impacts since the players are being hit with such tremendous force on this type of play. Also with football, instituting a “play clock” which requires a quarterback to get rid of the ball within 7 seconds or so of receiving the snap while preventing defenders from tackling him/her would possibly reduce a lot of injuries to quarterbacks who are being hit from behind while they are passing the ball. Rule changes such as these may not receive much consideration at the college or professional levels, but there is no reason why they can’t be instituted at the secondary school level.

The truth is that despite what we do with equipment or rule changes, concussions will never be completely eliminated. We may be able to reduce the risk of injury, but concussions can occur anywhere anytime, even during accidental contact with team mates, during non-contact sport or in any number of recreational activities. The focus should therefore be on the prevention of subsequent concussions that occur because a student-athlete is returned to physical activity before the original concussion has healed. And the big challenge with the prevention of second concussions is that up to 80% of all student-athletes who suffer a concussion are either not aware of their injury or they do not report the injury to their coach or parent. That is why we strongly recommend a Partner Approach to concussion management so that there are a number of people watching the student-athlete to spot signs and symptoms of concussion. With so many pairs of eyes on the student-athlete, it is hard to believe that a concussion would be missed. The responsibility is spread among a number of people instead of being placed squarely on the shoulders of a medial doctor.

So we are pretty sure that while legislation may not say much about preventative measures for original concussions, we are absolutely certain that all Student-Athlete Concussion Management Programs will be required to address in some manner the issue of prevention of repeat concussions. The quandary is that most legislative requirements will simply be satisfied with a written clearance to play from a medical doctor. Unfortunately, we don’t think that is enough to satisfy the courts if legal action is initiated by a parent/guardian. This is why we strongly recommend that any school board we are working with develops a program that also requires the parent/guardian, the student-athlete and the school Principal to give their clearances before returning to activity. In addition the school board should require, through neuropsychological assessment, objective evidence that the student-athlete has returned to pre-injury functionality. It’s all about returning the student-athlete to whatever levels of functioning were considered normal prior to the injury. When that has happened, then it is as safe as it can be to return to physical activity.

We do also recommend that school boards take definite steps to ensure that coaches are well qualified and trained in their respective sport and that play-safe protocols be part of the pre-season training of student-athletes. By showing student-athletes how to avoid placing themselves in danger during competition, we may be able to prevent some of the injuries. This may require the school board to pay for sport-specific training and qualifications sessions, but the investment will be well worth the cost.

Consideration may also be given to the number of competitive games and practices that are held during the season. For example, there is nothing wrong with playing one or two games a week. It is not necessary for teenagers and young adults to play four or five highly competitive games per week. It is also recommended that there be several days in between games and/or practices. This would allow a few days for minor sub-concussions to heal before being subjected to additional force that may lead to escalation of the injury into a full-blown concussion.

Coaches may also wish to consider policies such as no-body-checking or body contact during practices. This will reduce the risk of injury during practices which can often become pretty intense. In addition practices should never be scheduled the day after a game.

Finally, the whole issue of participating in tournaments needs to be given consideration with what we now know about concussions. A tournament may involve up to five or six games in a matter of a few days. That is a tremendous amount of highly competitive athletic competition in a short period of time which means that if the brain is vulnerable to injury, something is going to happen.

REMOVAL FROM ALL PHYSICAL ACTIVITY

It goes without saying that one of the provisions that must be included in any school board concussion management policy is that if a student-athlete is suspected of having sustained a concussion, he/she must be removed from further physical and/or cognitive activity immediately. This has become the standard procedure that is being recommended throughout the world. The key word here is “suspected”.
 
It is also easy to speculate that one of the provisions that you won’t find in legislation is a clear indication of who will be responsible for making the decision to remove a student-athlete from the game or activity. That would be leaving the person responsible open to liability.

Therefore, when it comes to the development of a Student-Athlete Concussion Management Program policy for school boards and post-secondary institutions, it is very important to spell out very clearly which people will be given the authority to make the decision, and not single out specific people who must make the decision.

That is a very important distinction. We feel that if we give the authority to school coaches, school leaders, and parents/guardians, and if we allow any one of them to initiate the protocol, then we will be spreading out the responsibility and be giving the authority to a number of people, thus reducing the likelihood of missing a concussion. We just need to make sure that our training establishes the criteria that are to be used to establish suspicion of having sustained a concussion and then make sure that everyone is well aware of them. Besides giving people the authority to make a decision, we must provide them with a level of expertise to help them when it comes time to exercise their authority.
 
To begin with, I think we would all agree that identifying a concussion can be extremely difficult. The school board policy therefore must clearly indicate that “any suspicion” will trigger the protocol. There cannot be a “degree of suspicion” or it will leave the decision open to interpretation, and since most of these decisions must be made quickly during a practice or game, there should not be any confusion or debate as to whether the suspicion is warranted. When it comes to concussions, you either have one or you don’t. You don’t “almost” have a concussion and you certainly don’t have the “beginning” of a concussion.

To use a comparison that is often used in other matters, a woman can’t be partly pregnant. She is either pregnant or she is not. Once a woman becomes pregnant the embryo grows into a baby. So it is with a concussion. You either have a concussion or you do not. A minor concussion can easily turn into a major life-altering injury if it is not managed properly.

Using the same example, we can also demonstrate one of the reasons why concussions are so dangerous. We all know that a woman can be pregnant before she has any obvious symptoms or before she does a test to determine pregnancy. Therefore, she can be pregnant without knowing she is pregnant. So too, you can have a concussion before you are actually aware you have a concussion and before you notice any of the universally accepted symptoms. So it is quite possible for a person to have a concussion without knowing it and then continue playing with a “time bomb” inside his/her skull ready to explode if the wrong move is made.

Therefore, while we may all agree on the basic concept of sitting out a player who is suspected of having a concussion, the criteria we use to arrive at the answer may not be quite so simple. And yet if a school board or post-secondary school policy includes the requirement that a student-athlete be removed from play if he/she is suspected of having a concussion, then we need to make sure that there is some criteria that will help determine when the suspicion takes effect. At the end of the day, if a judge has to decide the outcome of a liability claim, the question as to whether there should have been suspicion will certainly come up.  
 
There are universally accepted signs and symptoms that indicate the likelihood that a concussion has been sustained, but we need to know who is going to be given responsibility and/or the authority for making that call and what signs are going to be determining factors. Is there a “degree” of dizziness? Does the student-athlete have to be a little bit dazed or clearly dazed? Will it merely take a check to the head that initiates the protocol? Will simply doing a sideline test be enough to disregard the initial suspicion, or will the player need to be cleared by a physician? The main challenge here is that there are so many opinions and theories surrounding the identification of concussions that it is going to be difficult for any group of individuals to come to a consensus.

There are many who feel that a medical doctor is the only person who can diagnose a concussion. However, someone else is going to have to determine if there is enough evidence to warrant suspicion of a concussion so that the student-athlete is removed from play and taken to see a doctor in the first place. If everyone ignores the signs and symptoms, then by the time the student-athlete sees a doctor the damage may be life-altering.

We feel the best way to be sure that we are catching all of the signs and symptoms is to give everyone, including parents, teachers and coaches, the authority and the implied responsibility to be on the lookout for these signs and symptoms and then give all of them the authority to make the determination without having to justify or debate the merits of their decision. It is important that they understand that with the authority comes the “responsibility” and they cannot shirk their responsibility. They cannot stick their head in the sand and ignore the obvious signs hoping that someone else will step forward to make the decision. A concussion won’t go away just because we deny its existence. We must be accountable for both our actions and our inactions when it comes to the safety and well-being of student-athletes.

We also feel that there has to be a process in place to make sure that a student-athlete who is removed from play with a suspicion of concussion is also prevented from taking part in intramural games or physical education classes. Furthermore, the student-athlete must also be prevented from playing on his/her community minor sports team. That will then become the responsibility of the parents/guardians to communicate with the minor sports coach. This is something that must be made perfectly clear in the Student-Athlete Concussion Management Program adopted by the school board.

RETURN TO PLAY

We know that all legislation will include some sort of requirement that school boards include a section in their policy with respect to when a student-athlete will be permitted to return to physical activity. At the present time, the accepted practice is to have a doctor give this clearance. However, studies are providing evidence to support the fact that a concussion is a process that involves a variety of functional deficiencies that include not only physical, but also cognitive, mood and visual areas of the brain.

We strongly suggest that when establishing policies and guidelines respecting the return to physical activity, school boards should not only require clearance from a physician, but also at the very least clearances from the parent, the school, and the student-athlete  him/herself. 

We expect that the law may only require a doctor’s clearance before returning to play is permitted. However, unless clearances are also required from at least the parent and the school, we still may be putting the student-athlete at risk of returning before the first concussion has healed. A doctor cannot determine if all functionality is back to normal based on a ten minute visit. The doctor can determine if there are any bone fractures, internal bleeding or swelling of the brain. But a doctor cannot tell from observation or even from an interview if the student-athlete is having trouble sleeping or if he has a mood disorder that is different from before.

We also recommend the inclusion of a very specific step-by-step progression when it comes to return to play decisions. The Student-Athlete Concussion Management Program must establish guidelines for School Coaches, Student-Athletes and Parents/Guardians which deal with how quickly a student-athlete should be prepared for returning to competitive play and direction on what to do when symptoms return during the training phase. Our CMP Program Development Guide spells out these guidelines and we recommend that the school board program will include those or similar guidelines. We also feel that each school will have to design their own progression based on the facilities available. For example, if the school has a fitness area, then the progression may include so many minutes per day doing supervised training that is gradually building up resistance and endurance. This training should be documented so that there is evidence of what was done at this stage of rehabilitation.

ROLE OF SCHOOL LEADER

The ultimate responsibility for the safety of student-athletes still rests with the school. Therefore, the School Principal is the person who must ultimately accept this responsibility. We recommend that the concussion management program identify the School Leader or School Principal as the person who must give final clearance for a student-athlete to return to physical activity or competition. We understand that many programs specifically indicate that student-athletes require written clearance from a medical doctor in order to return to play, but our recommendation is that this medical clearance be only one of several clearances that are required. Hence, the medical clearance is not something that should be just handed to the coach and then the player put back into action.

The School Principal is responsible for overseeing all programs in his/her school, so if the student-athlete has received medical clearance to return to play, we accept that this is an important consideration. However, the School Principal must also take into consideration what is happening in the classroom and at home before allowing the student-athlete to put him/herself at risk for another concussion. Once clearances have been obtained from all parties, it is still up to the School Principal to weigh all of the facts before signing his/her name and allowing the student-athlete to return to play. It is after all, the School Principal who is responsible for the well-being of the students in his/her school.

RETURN TO LEARN

We expect that legislation is going to specifically mention “returning to learning” in addition to “returning to play”. This is going to be particularly challenging but because this is a functional injury to the brain there are going to be cognitive implications that will impact academics.

We feel that the parent/guardian should be the person who first decides when symptoms have subsided enough to permit their child to return to school. This will usually be within a day or two of the injury. However, once the student-athlete has returned to school, it will be necessary for teachers to have access to a very comprehensive guide that deals with the accommodations that may be necessary during the rehabilitation period. These accommodations are designed to prevent further injury and to reduce the return of symptoms from activities in the classroom.

It may take weeks or months before a student-athlete is ready to return to physical activity, but we do not recommend that the student-athlete stay out of school for the entire period of time. We feel that the student-athlete should be able to begin returning to his/her full academic level of responsibilities by gradually increasing the cognitive demands of the classroom. This must be a gradual, step-by-step progression much the same as the step-by-step physical activity progression that is followed when returning to competition.

In fact, there are studies that support the use of controlled cognitive stimulation to speed up the healing process. The stimulation of the brain cells in the damaged areas helps increase blood flow to those areas and helps the neural connections become re-established or restructured. Therefore, as soon as the symptoms subside, it is a good idea to begin taking small steps to return to normal activities in the classroom. That being said, care must be taken not to over do it and if symptoms return, then it is important to take a step back. The accommodations that are listed in Chapter Five – A Guide for Classroom Teachers should provide some excellent guidance for Teachers and we strongly recommend that they be part of a school board’s concussion management policy. We also provide similar suggestions to Student-Athletes in their guide which can be found in Chapter Six.

We anticipate that when reference is made to “returning to learning” the intent is returning to pre-injury learning levels and expectations. In that case, it will be the classroom teacher who is the best judge as to when the student is able to handle the normal rigours and workload of the classroom, including testing, homework, assignments, etc. Up until that time the classroom teacher will allow the student-athlete to function at a lower level of expectation than normal and also to be accommodated without the fear of losing his/her academic year. A concussion is a temporary learning disability and should be treated as such by classroom teachers.

DESIGNATION OF RESPONSIBILITIES

School Board policies will have to be very specific with respect to ” who” will be required to assume responsibility for the implementation of the various elements of the program. This means that in all likelihood the state or provincial governing body will give this responsibility to the Director of Education who will then delegate the task to one of the senior supervising officers.

We feel that it is best for the Student-Athlete Concussion Management Program to identify the School Principal, in the case of a school board, or the Athletic Director, in the case of a post-secondary institution, as the School CMP Leader taking charge of overseeing the implementation of the program at each individual school operated by the board. This will establish a chain of command so that if anything goes wrong or if there is a need to communicate, the links will be clearly established and everyone will know who makes the final decision.

We also suggest that the School Principal establish a School Leadership Committee consisting of the Vice-Principal, Phys. Ed. Department Head, and any other person who the Principal feels is qualified to assume a leadership role in the implementation of the program. This will give clarity as to who is in control of the program at any school and who has the responsibility for making final decisions with respect to the well being of student-athletes. It will also help share the workload for supervising the teams and activities that are being covered by the program at the school.

An Athletic Director should appoint key individuals in his/her Athletic Department as members of the School Leadership Committee for a post-secondary school situation.

In addition we feel that all coaches, including teacher-coaches and community volunteer coaches, should be trained by one of the School Leadership Committee members. This will once again give everyone confidence that the standards are going to be consistent and compliant with both legislation and school board policy. Some surveys indicate that upwards of 40% of coaches are not aware of a school board’s concussion management policies, so training and verification of training is extremely important when it comes to any program implementation. If a coach has attended a training session, then that coach can never say that he/she is unaware of the policy.

For each school team or activity, one of the trained School Coaches should be designated as the School CMP Head Coach, and that person will be responsible for ensuring that the program is implemented accordingly for the team. The School CMP Head Coach should also responsible for training all student-athletes on the team and for administering the neuropsychological testing. Once again, this gives some consistency to the program and clearly establishes a chain of command with respect to the concussion management program.

We feel that school boards are going to be required to be very clear and meticulous about elaborating on the roles and responsibilities of each of the partners in the concussion management program and we anticipate that any legislation will be just as methodical. Unless these responsibilities are clearly spelled out the entire identification and rehabilitation process may become paralyzed as people hesitate to step forward to take charge. In order to be an effective program everyone must know their job and must then be willing to execute those responsibilities accordingly.

Everyone will have a very important role to play in the Student-Athlete Concussion Management Program and when everyone does what they are supposed to do, the process will work well. The “partner approach” is dependent upon everyone knowing their responsibilities and then following through.

RESPONSIBILITIES OF NON-EMPLOYEES

Secondary schools rely upon community volunteers to assist with many of their sport programs, so any policy will need to address what roles community volunteer coaches have in the whole process. We are certain that legislation is going to address the role of non-employees or volunteers.

The Student-Athlete Concussion Management Program should make it clear that community volunteer coaches may work in any capacity with the team, but it is our recommendation that they should not be authorized to provide the training or supervise the neuropsychological testing of student-athletes. Those tasks should be done by the School CMP Head Coach or one of the School Coaches who is also a licensed, certified teacher on staff. The person doing the training should be accountable to the school board as an employee and should be a trained, professional educator in order to make sure that the person is qualified to teach what needs to be taught.

The legislation may also be specific as to what is expected from medical practitioners, athletic trainers, and other health care providers with respect to providing medical and clinical consultation reports.

It is entirely possible that the provincial or state legislation will require community volunteer coaches to be trained and/or qualified in some very specific manner in order to be able to work with the student-athletes. We felt that since school principals must accept responsibility for the well-being of all students while they are involved in school-sanctioned activities, community volunteer coaches should be required to take the same level of training as teaching staff coaches. We feel that the School Leader should also be able to require that community volunteer coaches hold some sort of sport-specific credentials when working with a school team.

NEUROPSYCHOLOGICAL TESTING

We anticipate that legislation will recommend the use of neuropsychological testing by school boards, but we do not believe that this is going to be a mandatory requirement.

For example, in Ontario , we have comprehensive Physical Education Safety Guidelines developed by the Ontario Physical and Health Education Association (OPHEA) in partnership with the Ontario School Boards’ Insurance Exchange (OSBIE), the Ontario Association for the Supervision of Physical and Health Education (OASPHE), the Canadian Intramural Recreation Association – Ontario (CIRA), and the Ontario Federation of School Athletic Associations (OFSAA). In that guideline it is stated that “A concussion is more successfully evaluated if the student/athlete completes a neuropsychological baseline evaluation prior to beginning the sport season.”

If a school board is to provide the highest standard of care possible for pupils enrolled in secondary schools, then it stands to reason that the policies and guidelines will require neuropsychological testing of some kind. At CMP we feel that the most reliable form of such a test is a computer based test done by ImPACT.

ImPACT is a computer-based battery of tests developed specifically for assessing sport-related concussion. The computer program measures multiple aspects of cognitive functioning, including attention span, working memory, sustained and selective attention time, response variability, and several facets of verbal/visual memory. This will register a “baseline” record of abilities of student-athlete with which to test against should they suffer a possible brain injury during the season.

While there are other neuropsychological tests on the market, the important thing for any school board to consider is “who” will be assessing the results of the tests. The professional most qualified to do this is a neuropsychologist who is familiar with sport-related concussions. The legislation will likely make it clear that simply using neuropsychological tests is not enough. The results must be assessed and evaluated by someone who is properly qualified.

We have incorporated detailed information about how to include neuropsychological evaluation into a school board’s student-athlete concussion management program. We will be recommending that the school board steering committee give serious consideration into the inclusion of this element into their program. In order to show how this evaluation works, we will be recommending that it be implemented in a “ Demonstration School ” for a year.

Neuropsychological evaluation is going to eventually become a necessary element of all school board student-athlete concussion management programs if for no other reason than for the fact that it provides evidence of the recovery of a student-athlete who has received a concussion.

DEADLINE FOR DEVELOPMENT OF POLICY

Most legislation is going to give school boards time to develop their own policies and guidelines. However, given the serious nature of concussions, we would expect that the deadline is going to be sooner rather than later. We all know that it takes time to develop policies, but there is a sense of urgency with respect to concussions.
 
Unfortunately, with up to 80% of concussions going undetected, this means that a lot of our student-athletes will be in grave danger of suffering long-term life-altering serious consequences from brain trauma while the experts are sitting around the table trying to come to a consensus. Therefore, individual school boards will serve their own students best if they come up with a solid program on their own and then make any necessary adjustments once the Bill is passed and the Ministry develops their policies, guidelines and regulations. There is no point in waiting for the government to spell out your responsibilities. School Boards and Post-Secondary Institutions have more than just a legal responsibility to their students.

This is one of the main reasons why we have developed our comprehensive CMP Student-Athlete Concussion Management Program as a framework model for individual school boards and post-secondary schools. We feel that if we begin meeting with a steering committee and can start with our CMP Program Development Guide, then it will take us much less time to add new provisions and amendments that will be considered satisfactory instead of starting out with blank pages. The CMP Program Development Guide will become the foundation upon which to develop the completed program and then we can implement it in a “ Demonstration School ”. This should speed up the process and allow school boards to implement a board-wide program for all schools within a year or two at the most. Post-Secondary Institutions will be able to establish the program for all of their varsity teams in a relatively short period of time. Time is of the essence when it comes to concussion management.

FREEDOM FROM LIABILITY

One of the most important sections of most legislation that we expect to be forthcoming from provinces and states is in the area of personal liability. We expect that legislation will make it clear that as long as a person acts “reasonably in the circumstances, in good faith and in accordance with the school board policies” that person will not be held liable in a civil proceeding for any act or omission. This will be pretty good immunity for anyone involved in sport-related activities at a school.

However, it is also a pretty clear warning to school boards that unless the board complies with “all” aspects of the legislation, then their employees and volunteers might be at risk for civil liability. The legislation will set the “standard” by which all legal cases will be measured. It will imply that due to the seriousness of brain injuries and the ever increasing public awareness that is being generated, there may be civil cases coming forward for acts and/or omissions when it comes to concussion identification and management.

This is one of the main reasons why we think this legislation is going to come sooner rather than later in most provinces and states. It also has implications for private schools which must comply with the directions from the Ministry of Education. Their own policies and guidelines will be judged according to the Act, regulations and any policies and guidelines that fall under the Act and regulations.

EVIDENCE TO SUPPORT COMPLIANCE

We are certain that most legislation will require some form of evidence to verify compliance. In anticipation of this we recommend that the Student-Athlete Concussion Management Training Program be a mandatory requirement for all School Leaders, School Coaches and student-athletes. The training should also be facilitated and witnessed by a qualified instructor and all who participate should be registered on a special data base operated by the school board. This means that if anyone has a question about the level of training, the school board will have clear proof of when and where the training took place as well as who did the training. We do not feel that this should be simply left to chance and we think we are going to have to do more than just take a person’s word for this. We recommend the use of video to ensure that there is consistency of training at all individual schools. This will again provide evidence as to the nature of the core curriculum of the training which we will ensure is going to be compliant with the legislation on its own.

A Local Registry will also help School Coaches determine if any of their players have not yet taken the course. When the players begin try-outs the School Coaches will at least know that every single student-athlete has received the same basic training about concussions.

School Board and Post-Secondary School policy should also require that all student-athletes receive a neuropsychological test every two years. It will be relatively easy to produce a listing of all student-athletes who have taken a valid baseline test, but only Dr. Czarnota will be able to access the records.

We feel confident that if a school board or post-secondary school incorporates the elements we have put together in our CMP Student-Athlete Concussion Management Program framework model, it will have ensured that there will be ample evidence and tracking of all activities that fall under the school board concussion management program. We also believe that this will be of great benefit to the school board and will be in the best interests of all student-athletes.

RECOMMENDATIONS FROM INSURANCE COMPANY

Do not expect to receive any form of recommendation from your insurance company when it comes to procedures or the use of neuropsychological testing. Insurance companies will provide coverage, but they generally do not want to get involved in any of the decision-making or policy development for fear that they may be held accountable for any consequences. This lack of recommendation does not necessarily mean that they disapprove of the use of testing, for instance. It just means that they want to keep their opinions to themselves.

This means that when you are designing your own program, you must be satisfied that it meets the strictest of tests with respect to risk management that you could possibly require. You must be absolutely confident that your policies will be compliant with existing legislation and expectations.

For example, there are some insurance companies that state that if the law does not require you to include neuropsychological testing, then it is best not to include it. Not because your program will be more effective without it, but simply because you then must ensure that the testing be used consistently and properly by all schools. That is why we recommend that schools allow the CMP Consulting Neuropsychologists to be responsible for all of the assessments and reports on baseline and post-injury testing. If the school board is merely responsible for administering the tests in accordance with our specific guidelines and procedures, then there is very little, if any risk on the part of the school board and the use of the program will be definitely applied on a consistent basis meeting the highest of standards. A school board that wishes to purchase their own program and then do their own training may find it more difficult to avoid responsibility if this test for consistency fails.

ROLE OF GAME OFFICIALS

When it comes to safety of athletes during competition, game officials have a tremendous responsibility placed upon their shoulders. While they must ensure that the rules of play are followed, they must also be aware of the condition of players who are engaged in the competition. If they feel that a player is significantly injured, they must stop the play and signal to coaches and trainers to come onto the playing surface to attend to the injured player. When it comes to concussions, game officials may find themselves particularly challenged.

We are all aware that a concussion is a traumatic brain injury that is caused by a force to the head or body which is strong enough to cause movement of the brain which in turn leads to some form of functional impairment. There are universally accepted signs that indicate a person has a concussion, but during the course of a game, some of those signs may not be evident.

We recommend that the school board concussion management program should make it perfectly clear that when game official points out a sign or symptom that may indicate one of the players may have a concussion, then the concussion management protocols should be immediately implemented. This will establish “probability” that a concussion exists. That means that the student-athlete is taken out of the game and will require clearances from a doctor, parent, the student-athlete him/herself, and a neuropsychological assessment that indicates he/she is at baseline levels. Only then may the school principal sign a clearance for the student-athlete to return to physical training supervised by the coach.

We strongly recommend that even if the local athletic association rules permit a player to be returned to the same game if an off-ice health professional determines that a concussion exists, the student-athlete should never be allowed to return to play that game. It should take about 7 days at the minimum in order to make sure that there are no longer any concussion symptoms observed by any of the persons involved with the student-athlete.

As a final note, coaches should understand the position that game officials are put in when they must ask a player to leave because of concussion-like symptoms. These are signs and symptoms that should be noticed by the coaching staff first. Game officials do not like being forced to make decisions that should be the responsibility of the coaching staff. If a game official finds it necessary to ask a player to leave the game, then there should be an investigation done by the league to determine why the coaching staff did not make the call. The onus should always be on the coaching staff to ensure the safety of his/her student-athletes.

We hope you understand that we are not taking anything away from medical professionals who may be at the game. Remember our basic philosophy is that we act on a “presumption of concussion” when identifying a concussion, but we need to apply the test of “beyond a reasonable doubt” when we decide to return a student-athlete with a suspected concussion to play again. This means that all “partners”, including the medical professional, the parents/guardians, the school coach, the classroom teachers, the student-athlete, and the School Leader all must be absolutely certain that the student-athlete is free from symptoms and safe to return to physical activity.

CMP CONCUSSION MANAGEMENT PARTNERS INC.
Serving Canada & the United States
Offices in the Province of Ontario and the State of Michigan
email: rkirwan@infocomcanada.com   Phone: (705) 969-7215