Best Practices in Concussion Management

Before 2009, no states had legislation specific to concussion on the books. Today, all 50 states do.1 It's important for physical education teachers to understand concussion legislation for their state and also be knowledgeable about best practices in concussion management.

When in Doubt, Sit Them Out

The most common guideline in concussion legislation is removing the student from play when a concussion is suspected.2 Referred to commonly as “when in doubt, sit them out,” this guideline mandates coaches and responsible adults to err on the side of caution.

While only medical professionals can or should diagnose a concussion, a physical educator or coach who recognizes any of the common signs of concussion — or has reason to suspect that a student has been concussed — should remove the student from play until he or she is assessed by a qualified person and cleared to resume play. Consult your local or state authority for more specific guidance.

Return to Play

Another common best practice is having a return-to-play progression, also known as a graduated return-to-sport strategy.

As displayed in Table 1, these guidelines prescribe a progression through increasingly strenuous activities as the student is able to manage and tolerate.3 Of course, this progression does not begin until the student has been cleared by a healthcare professional.


Table 1. Typical Return-to-Play Progression

 The Aim

Symptom-limited activity

 The Activity

Daily activities that do not provoke symptoms

 The Goal of Each Step

Gradual reintroduction of school and/or work activities

 The Aim

Light aerobic exercise

 The Activity

Walking or stationary cycling at slow to medium pace; no resistance training

 The Goal of Each Step

Increase heart rate

 The Aim

Sport-specific exercise

 The Activity

Running or skating drills; no head-impact activities

 The Goal of Each Step

Add movement

 The Aim

Non-contact training drills

 The Activity

More difficult training drills (e.g., passing drills); may start progressive resistance training

 The Goal of Each Step

Exercise, coordination & increased thinking

 The Aim

Full contact practice

 The Activity

Following medical clearance, participate in normal training activities

 The Goal of Each Step

Restore confidence and assess functional skills by coaching staff

 The Aim

Return to sport

 The Activity

Normal game play

 The Goal of Each Step

 

See: Return to play integrating the child back to physical activity following a concussion

 

Return to Learn

A best practice that has gained increasing support in recent years is a graduated return-to-learn progression. Many of the signs and symptoms associated with concussion can affect a student’s ability to participate in normal academic activities (e.g. focusing in class, completing homework, studying).

While most states incorporate a return-to-play progression, few require a return-to-learn progression.2 Still, this is a best practice because symptoms such as headaches, sensitivity to light and difficulty with concentration and memory can leave a student-athlete incapable of performing at his or her normal level.

Using similar logic, a progressive return to normal learning activities makes sense. See Table 2 for a typical progression. It’s important to find out whether your local or state authorities require such a progression or not.

But remember, legislation represents minimum requirements. If such a progression is not required, it certainly can be added to local policies and protocols as a best practice.


Table 2. Typical Graduated Return-to-Learn Progression

 The Aim

Daily activities at home that do not give the child symptoms

 The Activity

Typical day-to-day activities (e.g., reading, texting, screen time) so long as the activity does not aggravate symptoms; start with 5-15 minutes at a time & build gradually

 The Goal of Each Step

Gradual return to typical activities

 The Aim

School activities

 The Activity

Homework, reading or other cognitive activities outside of the classroom

 The Goal of Each Step

Increase tolerance to cognitive work

 The Aim

Return to school part-time

 The Activity

Gradual introduction of schoolwork; may need to start with a partial school day or with increased breaks during the day

 The Goal of Each Step

Increase academic activities

 The Aim

Return to school full time

 The Activity

Increase school activities gradually until student can tolerate a full day

 The Goal of Each Step

Return to full academic activities and catch up on missed work

See: Return to learn: integrating the child back to the classroom following a concussion

 

Multidisciplinary Teams

Many states specify that schools and/or local education authorities must form multidisciplinary concussion-management teams to set local policy and emergency action plans. With varying degrees of specificity, state legislation can include requirements or recommendations as to who should be included on such a team.4

Typically, represented groups include school staff and/or administration, family members, medical professionals and school personnel responsible for physical activity. See Table 3 for examples of typical members, but look to your own policies for specific requirements.

Table 3. Typical Representation on Multidisciplinary Teams

School Concussion Oversight Team

Teacher
School counselor
School psychologist
Social worker
School nurse
School administrator

Family Team

Student
Parents/guardians
Peers
Teammates
Family & friends

Medical Team

Emergency department
Primary care physician
Neurologist
Concussion specialist
Neuropsychologist
Athletic trainer
Physical therapist
Occupational therapist

School Physical Activity Team

School nurse
Athletic trainer
Physical educator
Coach playground/recess coordinator

For an example, see: Illinois Public Act 099-0245: Youth Sports Concussion Safety Act.

 

Concussion Education

Most state concussion laws include some requirements related to concussion education.6 These vary widely in terms of specificity. Some prescribe a certain number of hours of concussion education that must be renewed periodically (e.g., every two years). Some specify who must satisfy these requirements (e.g., coaches), and some provide examples of approved sources of education.

While concussion education is logical and important, such requirements take very different forms and often are ambiguous. Physical education teachers should begin by researching state and local policies to understand minimal requirements.2 Remember, though, that these are only minimums.

Also, even if your state doesn’t require concussion training, you might want to be proactive and at least meet the local standards. For example, a given state may not require concussion education for coaches in private schools even though the importance of understanding concussion is just as important for their professional practice as their peers coaching in public schools.



References:

1 Potteiger, A. & Wright, P. M. (2016). What you should know about your school’s concussion policy. Strategies: A Journal for Physical and Sport Educators, 29, 48-51.

2 Potteiger, K., Potteiger, A., Pitney, B. & Wright, P. M. (2018). An examination of concussion legislation in the United States. Internet Journal of Allied Health Sciences and Practice, 16(2), Article 6.

3 McCrory, P., Meeuwisse, W., Dvořák, J., et al. (2017). Consensus statement on concussion in sport- the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 51,838-847. Retrieved from bjsm.bmj.com/content/51/11/838.

4 Potteiger, A. & Wright, P. M. (2016). What you should know about your school’s concussion policy. Strategies: A Journal for Physical and Sport Educators, 29, 48-51.