"Learn from Yesterday;  Live for Today;  Hope for Tomorrow. 
The important thing is not to stop questioning." Albert Einstein

Unique Rehabilitation Program 
Designed to Help Your Child 
Return to School

School and Home Rehabilitation Plan Will Be Worked Out With Classroom Teachers

Specific Strategies Designed to Reduce The Risk of Repeat Concussions

CMP CONCUSSION MANAGEMENT TRAINING COURSE

INTRODUCTION

1. You now have a good understanding of what happens to the brain when it suffers trauma that leads to concussion. 
    

2. You also know why it is important for student-athletes to have baseline neuropsychological testing in order to help us identify when a concussion has occurred and to follow the recovery progress during rehabilitation. 
     

3. Finally, you are fully aware of the roles and responsibilities of the various partners in the CMP Student-Athlete Concussion Management Program and you should appreciate how School CMP Leaders, School CMP Coaches, Community CMP Coaches, classroom teachers, parents/guardians, the CMP Consulting Neuropsychologists and test evaluators, the family physician, and the student-athlete all work together to reduce the risk of long-term permanent consequences that may result from an initial injury to the brain. 

Now we will examine the CMP Concussion Identification & Rehabilitation Protocols and see how this program is put into action in real life.

Initiating the Process

If a student-athlete receives a blow to the body or head during practice or competition that in the opinion of any one or more of the School CMP Coaches, the Community CMP Coaches, the Parent/Guardian, or a School CMP Leader, may have been sufficient enough to have caused a concussion, then the player “must” be observed extremely closely in the period following the incident. 

This period of "watchful waiting" for signs and symptoms to present themselves is extremely important. We want to avoid "jumping to a diagnosis" every time a student-athlete experiences a blow to the body or head, but it is a very critical period when things may happen quickly. Therefore, we do not want to miss out on any of the obvious signs of concussion.

If any of the universally accepted signs or symptoms of concussion are evident, then the player must be removed from further play and the CMP Student-Athlete Concussion Identification & Rehabilitation Protocol will be initiated immediately.

There can be no hesitation in making this decision. There can be no debating the merits of the decision. In other words, if a parent/guardian of a student-athlete approaches the coach during the game and informs that coach that his/her son/daughter appears to have been injured and that the parent/guardian would like to initiate the CMP Concussion Identification & Rehabilitation Protocol, there is to be no hesitation on the part of the coach. The student-athlete will be removed from action immediately and the process will begin. 

The student-athlete must also understand that this is in his/her own best interests and is expected to go along with the decision without causing any grief. After all, the student-athlete will have gone through this same certification course and will know the consequences of concussion. We don't want to see any arguing on the part of the Student-Athlete to remain in the game.

The fact that we have so many pairs of eyes observing student-athletes in competition should help us spot the universally accepted signs that will give us cause for concern.

Threshold Differences Among and Within Players

We will mention this point several times on the web site and in our curriculum content, but it is so important that we simply cannot mention it often enough.

Keep in mind that all student-athletes will react differently when it comes to concussions. Some athletes will receive what initially may appear to be a serious blow to the head or body and will be fine. Others will receive what appears to be an insignificant blow to the head or body and they will suffer from the effects of a concussion for months. 

There is no objective test for forces that will produce concussions. There is no magic measurement that provides the line over which a concussion will occur. It is entirely different for each person. That is why we do not recommend placing much confidence in the use of sensors that are attached to helmets. It is impossible to determine the level of force that will cause a concussion in any individual.

To make matters even more challenging, each individual has different internal thresholds from time to time. Therefore, it is quite likely that there will be times when a student-athlete will receive a blow that one would expect to be serious enough to cause a concussion and he/she will be perfectly fine. Then there may be other times when a seemingly insignificant blow will cause a major concussion. Research is still being done to determine if this phenomenon is the result of a number of sub-concussive blows to the body that accumulate until they reach a breaking point. The problem is that since it is impossible to measure accurately whether or not a concussion has occurred, you can imagine how hard it would be to measure sub-concussions.

Therefore, our recommendation is for all partners to be constantly on the look out for signs and symptoms of a concussion, regardless of the level of force that the student-athlete has experienced. Also, it is important to keep in mind that some symptoms of concussion do not come out immediately after the hit. It sometimes takes hours or days for some symptoms to emerge. Once again, it is important for parents, coaches and teachers to be observant for these signs and symptoms because there may be some very minute, almost indistinguishable signs that are evident or that become evident that would require immediate action. Keep in mind that even if some of the symptoms do not present themselves right away, the internal damage to the brain has occurred and leaves the brain vulnerable to much more serious consequences.

Do not fall into the dangerous trap of thinking that if the force of the blow was insignificant, the signs cannot be attributed to concussion. It doesn't take long to do a post-injury neuropsychological test and to put everyone on notice as part of the rehabilitation program. You may only need to initiate the program for several days, but when it comes to brain injury, it is always better to be safe than sorry. There is just too much risk to ignore the real possibility of a concussion.

So, once again, regardless of whether or not a player has had concussions in the past, or the level of impact that was experienced, we must always be on the look out for signs and symptoms of concussion - just in case - and be prepared to initiate the protocols that are outlined below in this section.

Signs to Look For

Keep in mind that everyone must be on the look out for the following signs when a student-athlete suffers a serious blow to the head or body. We will once again acknowledge that not all hard hits will result in a concussion. In fact most physical contact during competition and/or practice will be fine and players will simply continue to enjoy the game. 

Therefore, as mentioned previously, we are not suggesting that every time forceful contact is made with a student-athlete we should be pulling the player from the game. However, knowing what we know about concussions, and especially when we are now aware of the fact that upwards of 80% of all concussions go unreported when they first occur, it is critical that all CMP Partners be on the lookout for tell-tale signs of concussion after a significant blow to the body or head has occurred. The student-athlete may not even be aware of the signs him/herself. However, there are enough other people around who know what to look for so someone should spot any problem.

We should also keep in mind that the signs we are looking for will either be cognitive or physical, or a combination of both.

NOTE: It goes without saying that if the student-athlete loses consciousness, even for a few seconds, there is to be no further observation. We will automatically assume that the person has suffered a concussion and will immediately initiate the protocols.

If any of the following are observed, we “must” assume that a concussion has occurred until we have evidence to the contrary. We should never ignore any of these signs in a student-athlete who:

1. appears to be dazed or stunned immediately after the incident, even if only for a few seconds;
    

2. seems to be confused about his position or assignment during the game or on the bench;  
    

3. is not sure of the score, the period, the opponent, the time, etc. when questioned by coaches;  
    

4. seems to move clumsily on the field/ice or around the bench/dressing room, displaying balance issues;  
    

5. responds to questions with a bit of hesitation or not at all, demonstrating a delay in processing information;  
    

6. seems irritable or displays uncharacteristic mood/personality changes which are out of the ordinary;  
    

7. can’t recall the play where he got injured, even if he says he is fine;  
    

8. can’t recall what happened after he got injured;
    

9. seems easily distracted with poor concentration;
    

10. has a vacant stare or seems to have glassy eyes;
     

11. is slurring his speech;
     

12. seems to be having minor convulsions or seizures;

Symptoms To Look For

Besides the “signs” that may be evident, if the student-athlete reports any of the following symptoms, the School CMP Coach or the Community CMP Coach must remove the player from further play. Symptoms will usually be identified by the student-athlete but he/she may not articulate the symptom clearly. We must be able to "read' the student-athlete. 

The following self-admitted symptoms are absolutely serious enough to assume a concussion has occurred so the CMP Concussion Identification Protocol will immediately be put into action when the student-athlete:

• complains of headache or pressure inside the head, even if it is only a slight pain;  
   

• complains of dizziness or trouble keeping his balance;  
   

• is feeling nauseous or feels like vomiting;
     

• complains of vision problems;  
   

• states that he is sensitive to light or noise;  
   

• complains about feeling sluggish, foggy or groggy;  
     

• says he/she is feeling confused;  
     

• says he/she is just not feeling right;
   

• says he/she is seeing stars;
   

• complains about a ringing in his/her ears  

Hidden Symptoms

The greatest challenge when it comes to identifying a concussion is that so few symptoms are visible to the casual observer. Many times the symptoms of a concussion may not be identified until the person recovers to the point where increased exertion causes symptoms to worsen. Studies have shown that as many as 4 out of 5 professional athletes do not even know that they have been concussed so imagine how difficult it is for a student-athlete to be able to understand what is going on in his/her body?

This is why one of the goals of CMP is to make sure that all adults who are involved in any way with student-athletes are as prepared as possible to look for the signs of concussion and then take appropriate action to remove the player from further play to avoid the possibility of further damage.

CMP recommends that even if there are no apparent signs and the student-athlete reports no symptoms, if a School CMP Coach, the parent/guardian and/or the School CMP Leader has a strong suspicion that a particularly hard blow to the body or head area may be cause for concern, then it is at the discretion of any one or more of them to initiate the protocol and request that the School CMP Coach remove the player from further action.

We always recommend erring on the side of caution, so even if it means going through the steps of the CMP protocol to find out that there was no concussion, it is worth the inconvenience for a week to be sure that there is little risk of long-term damage to the student-athlete. 

We will never be upset with a CMP Partner who initiates the protocol. It will be clearly understood that you are acting out of care and concern for the student-athlete and if it turns out to be a false alarm, we won't be upset. To the contrary. We will be happy that there is no damage.

There is, however, no excuse for ignoring obvious signs and symptoms. We feel that with so many “partners” looking out for the safety of the student-athlete, someone will see a sign or recognize a symptom if it comes up.

Parents and coaches of school teams must always keep in mind that up until the age of 19 or 20 the human brain is still developing and neural connections are still forming and strengthening. Therefore, any brain trauma that results in a temporary dysfunction has the potential for changing the course of a person’s life as a result of some degree of impaired cognitive ability. There is no such thing as a minor concussion. All concussions are serious and all have the potential to cause significant damage to an individual’s future development. Do not be fooled by the term "mild traumatic brain injury" or "temporary". The truth is that we don't know enough about concussions to state categorically that the injury is mild or temporary.

Case studies have been done producing evidence that young students who have had one or two concussions have become easily distracted and have had to drop out of advanced classes after having been top students their entire life. Others have struggled with memory loss, poor concentration, depression and low confidence that significantly affect their academic potential and thus influence their entire life. The bottom line is that while many people focus on the temporary nature of the most obvious symptoms, the long-lasting consequences may be devastating to a young person’s future. This is why we must do everything we can to prevent repeat concussions among student-athletes.

We must acknowledge that a concussion may evolve into a personality disorder and can actually lead to inappropriate labeling of mental and learning disabilities. Interpsychic conflict will present itself in a variety of unpredictable symptoms over time as cognitive deficiencies evolve.  Student-athletes may find that normal activities that were automatic, now require significant effort. For example, recalling their own phone number; doing simply math calculations; providing simple directions; etc. Once the student-athlete finds these simple things challenging, there is a tendency to become frightened about the prospects for recovery.

This means that we must go beyond the obvious symptoms. Some deficiencies may resolve quickly as the brain repairs itself while others will be permanent and require careful and deliberate rehabilitation in order to help the brain restructure in a way that will return the student-athlete to "near baseline" functions. This is where teachers and parents/guardians play a huge role in the recovery process. Teachers and parents must be aware that the dividing line between depression and unhappiness is hard to distinguish. Many student-athletes will be unhappy with their rate of recovery and unfortunately may perhaps be diagnosed as being depressed. There is a big difference in the label and it is incumbent upon teachers and parents/guardians to make sure that they guide the student-athlete through these periods of unhappiness.
 
What we do know is that a concussion is a brain injury that changes the way the brain functions and hence produces changes to the person who is injured. We are dealing mostly with sport-related concussions at this time, but it doesn't matter how the injury occurs, when you are told that one of your students has a concussion it means that this injury will affect the performance of that student in your classroom. What you do to assist the student in the classroom will have a profound impact on helping the student recover from the concussion.
  
When a student-athlete experiences the kind of force that results in a concussion it means that the brain has bounced around or twisted sufficiently to cause stretching and damage to the brain cells, creating chemical changes inside the brain and changing the communication network between the cells. Since concussions affect people differently, we can never say if an injured student will recover in a few days or a few months, or longer. The reconfiguration and reorganization of the brain cells may lead to changes that can set off a series of symptoms that result in learning problems, poor academic performance, and may also have a profound affect on a wide range of cognitive, physical and emotional areas.

RECOVERY PROCESS IN ADOLESCENTS

If there is one thing we are all learning from latest research into the brain, it is that not knowing what you are doing when it comes to concussion management can change who you are and who you could have become. This is not turning out to be as temporary a dysfunction as we previously were lead to believe. 

Many men and women in their 40's and 50's are now discovering that the multiple concussions and subconcussions they may have passed off as insignificant when they were younger are now showing up in symptoms such as depression, anxiety, mood disorders, memory loss, early onset dementia, suicidal thoughts, relationship problems, irritability, and the list goes on and on. 

Those persistent headaches that keep coming back when you attempt a particular activity. The dizzy spells that come now and then. The personality change you went through during adolescence. All of these things may have something to do with brain trauma you experienced over the years.

Furthermore, with all of the attention being given to concussion management, we are seeing evidence that after an athlete has been deemed to have recovered from a concussion, he/she may not always return to the same level of functioning in all areas of his/her life. For example, once declared healthy following a rehabilitation program,  many professional athletes are never able to regain quite the same level of performance they enjoyed prior to the original injury. Their reaction time may have changed, ever so slightly, but just enough to have an impact. They may not be quite as fearless as they once were, or they may be more reckless, thus putting themselves at greater risk of injury.

This leads us to the plausible spectulation that the injuries sustained by the brain when one is concussed may not ever totally heal. In fact, during the rehabilitation process it is possible that the synaptic architecture within the brain is reconstructed and that this reconstruction may not completely replace the original architecture. More will be said about this later on in this section, but rehabilitation may in fact be better thought of as the re-learning of skills. This re-learning may be faster than when the skills were originally developed because not all of the neural connections were lost or damaged as a result of the concussion. There may be enough left so that the skills can be brought back "close" to the pre-injury level, but just not exactly the same.

SERIOUS IMPLICATIONS FOR ADOLESCENTS

With respect to adolescents (children from the age of 13 to 19) we now must accept that a concussion is indeed a type of traumatic brain injury that actually changes the way the brain functions. To add further confusion to the mix, there are now two schools of thought emerging on the impact of concussions on young brains.

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. 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 will have serious consequences on a young adolescent brain.

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. 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. This is why we spend a great deal of time and energy emphasizing the importance of all partners being completely satisfied that all signs and symptoms have been resolved before even beginning to return to physical activity.

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 potential for reorganization of the neural connections in the brain compared with adults. The fact that the developing brain has double the neural connections of an adult means that the excess connections will allow for neural rerouting during the recovery period.

It 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 because it has so many extra neural routes that can be used.

What is not completely understood is whether or not the reorganization and rerouting can ever accomplish the same results because of the widespread impact of the original injury on so many other regions of the brain.

Another concern is that there may be areas of the brain that are not reconstructed simply because they involve functions that may not be commonly drawn upon by the student-athlete. This may explain changes in behaviour or personality that occur following a brain injury. 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 resharpen the skills of the player, he/she must also pay attention to the motivation and rebuilding of attitude and passion to the game so that both areas are brought back to pre-injury levels.

Therefore, the general consensus that teenagers take longer to recover from brain injuries may simply be due to the fact that teenagers who don’t allow sufficient time for the original injury to heal may in fact never recover from their injury, but rather they may develop new connections that may give them almost the same functionality as they had pre-injury. This means that it is even more critical that student-athletes take more time to ensure that their concussion has had enough time to heal so that they do not end up generating a rerouting or reorganization that may be life-altering.
 
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 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.

Not Aware of Injury

When it comes to identifying concussion in youth sports, we run into several significant challenges:

1. student-athletes may have sustained a concussion and may actually not be aware of it at the time. With so much going on inside the developing brain of an adolescent, it may be difficult to distinguish between normal inconsistencies and changes and concussions;
    

2. student-athletes may think there is something wrong but haven’t told anyone about how they feel in order to remain playing. We know that adolescents are prone to risky activities. They also think they are invincible and can do anything. Their need for peer approval may be stronger than their need for safety and many of them simply refuse to acknowledge injuries that will take them out of action;
    

3. student-athletes may think there is something wrong but haven't told anyone about how they feel because they are unable to articulate their symptoms. Adolescents are self-conscious and may be too embarrassed to attempt to describe their symptoms if they have trouble coming up with accurate descriptions. They may just hope that the symptoms go away and decide to cover up.

In one study a sports medicine specialist followed two junior hockey teams for a full season. Keep in mind that these are players ranging in age from 16 to 21 and the teams have a trained sports medicine specialist on site for every game. During the study which included 52 games, there were 21 concussions. Only three of the concussions were self-admitted by the players. More than one in four of those 21 players sustained another or recurrent concussion during that same season. This points out the importance of making sure that coaches, parents and school leaders are well educated with respect to the identification of concussion signs and symptoms. The student-athletes themselves may not self-admit their symptoms, but they usually cannot hide their signs from everyone.

TRANSITION BETWEEN IDENTIFICATION & REHABILITATION

Once a concussion has been “suspected” because of the signs and symptoms that have been observed, it is important to develop a personalized rehabilitation program that takes into consideration a number of crucial factors. 

Unfortunately, the one thing that most experts agree with is that there is no universally accepted guideline that has proven to be dependable or practical in all situations. It is now accepted by most experts in the field that each concussion should be managed on its own merit using multiple means of assessment and rehabilitation protocols.

This means that if a concussion is “suspected”, we must take the position that a concussion has been “identified” until we can prove otherwise. The suspicion is all we need to justify initiating  the full process as if the concussion has been identified.

This is an important point! 

We cannot wait until we have done all of the steps necessary to identify an injury to the brain before beginning the rehabilitation process. If we "suspect" the "possibility" of a concussion, then we must begin the rehabilitation procedures and immediately take precautionary steps "just in case" our suspicions prove accurate.

Therefore, the transition period between "suspecting" a concussion and the actual "identification" of a concussion is when we must begin the rehabilitation process. If we wait until a concussion is definitely identified before beginning the rehabilitation process we may end up acerbating the situation and make matters worse. If we happen to begin the rehabilitation process and find out that there is no positive evidence of a concussion, then what damage have we done? Nothing!

Subsequently, once the CMP Concussion Management Protocols are initiated, we will always "assume" that a concussion has occurred until it is proven otherwise. I cannot state this enough. We must follow through with all of the steps.

FIRST ORDER OF BUSINESS - PHYSICAL AND COGNITIVE REST

At the present time the treatment for concussion consists of both physical and cognitive rest until all symptoms have subsided. Most people can understand the physical rest requirement, but experts agree that cognitive or brain rest is critical, especially during the first several hours and days.

We have already discussed how the brain may continue to deteriorate following an injury, and since the conditions in and around the brain after an injury are not all that conducive to healing, it is absolutely imperative that we reduce as much as possible any unnecessary activity that will cause the brain cells to experience any form of stress, no matter how trivial it may seem. 

This means that when an injured student athlete goes home after the injury, there should be no television or radio, no use of the computer, no cell phones or text messaging, no reading, no MP3 players, and no playing of video games. You must also keep your conversations to a minimum in order to give your brain complete rest and allow healing to take place. 

Any stimulation in the first 24 hours could seriously jeopardize the rehabilitation process. The student-athlete should go home and get some rest, in a quiet, dark room. This is the case even if the student-athlete says that he/she is no longer feeling any symptoms by the time he/she arrives home. And by all means, if symptoms seem to get worse or more intense as the evening goes on, the parents/guardians must bring their child to the hospital for an immediate check-up. Time is of the essence when you are dealing with serious brain injuries.

The student-athlete should take it easy for a full day before even thinking of going back to school.

CONCUSSION MANAGEMENT PROTOCOL

So let’s continue with the Concussion Management Protocols.  

Examination by Family Physician
 

4.       Depending on the severity of the injury, the Parent/Guardian will bring the student-athlete to see an emergency department physician, a family doctor, or a sport medicine physician at the earliest opportunity. 
 
Regardless of who you see, it is extremely important that we rule out any physical damage from the injury and this can only be done by a physician. Keep in mind that in some cases it is possible to have a fractured skull or some other physical injury without having any brain dysfunction. In those cases the student-athlete may not have a concussion but may have a physical injury that requires rehabilitation of a different kind. We want to check for all possible damage.

Parent/Guardian Home Care

5.      The Parent/Guardian will continue to monitor their child for signs and symptoms during the hours and days following an injury. 
 

6.   In particular, until the student-athlete sees a physician and completes a post-injury ImPACT test, the parent/guardian should see to it that their child avoids mental exertion such as working on the computer, texting, talking on the cell phone, playing video games, listening to loud music, watching television or anything else that involves mental exertion. 

As the symptoms begin to subside over the first couple of days, the child can be allowed to build up mental exertion in 30 minute increments. 

Within a day or two, if the symptoms have pretty well cleared while at rest, the child should be able to attend school on a modified program. The parent/guardian will discuss this program with the School CMP Leader or designate as well as the student-athlete’s classroom teachers.

Post-Injury ImPACT Test

7.      The Parent/Guardian will bring the student-athlete to school 24 to 72 hours after the injury for a post-injury ImPACT test that will be administered by the School CMP Leader or designate. We recommend that the parent/guardian wait for 24 hours at least in order to make sure that the brain has had a chance to settle down from the initial injury. As mentioned earlier, a concussion is a process and often the symptoms do not exhibit themselves immediately. As long as the student-athlete is avoiding any physical or mental exertion that is aggravating the symptoms, it is safe to go back to school and resume very limited physical activity such as walking and light aerobic exercise such as riding a stationary bike without resistance. We still must caution that any activity that causes symptoms to return must be stopped immediately.
  

8.   The School CMP Leader or designate will notify CMP that a post-injury ImPACT test has been submitted and will provide all of the necessary details about the incident and the student-athlete involved. This information will be sent by email and the School CMP Leader or designate must make sure that he/she receives confirmation that the message has been received. We will make sure to send confirmation of receipt of the information if we do in fact receive the message.
 

9.       If the results of the post-injury ImPACT test show evidence of diminished functioning as compared to the student-athlete’s baseline score, CMP will advise the School CMP Leader or designate that clearance to return to physical training should be delayed until another test can be performed at a date that will be recommended by CMP. We will always send a report back to the school within a reasonable time after receiving a post-injury ImPACT test.

Academic Related Accommodations At School and At Home
 

10.   The School CMP Leader and/or the School CMP Head Coach will notify all of the student-athlete’s teachers about the incident and remind the teachers about the accommodations that are expected when the student-athlete returns to school. 
 

11.   CMP acknowledges that classroom Teachers play a huge role in the rehabilitation process for a student-athlete who suffers from a concussion. Any stress or pressure on the brain may bring on symptoms and could delay the recovery process. 

Among other things, during the first few days after the injury teachers should: 

• Find an alternative to testing. Don’t simply delay testing.

• Allow someone to copy notes for the student athlete or permit taping of lessons  

• No physical education classes, including weight training or aerobics  

• Do not assign homework until the student-athlete indicates he is capable 

• Once the student is able to do some homework, provide written instructions  

• Have the student sit near the front of the room or where there are the fewest distractions  

• If the lighting bothers the student, perhaps the lights over the student can be dimmed  

• Allow the student to wear sunglasses or a hat with a visor if the light bothers him/her  

• Allow the student to visit with the counsellor whenever he/she requests  

• Allow the student to move from class to class before the hallway gets crowded  

• Allow the student to take lunch in a quiet place with one or two friends only  

• waive time constraints for tests and assignments – take as long as necessary to complete  

• be flexible with respect to assignment due dates  

• don’t expect the student to catch up on missed lessons – adjust the expectations

• provide preferential seating for close monitoring and decreased distractions  

• allow the student-athlete to leave the room if he/she is feeling overwhelmed  

• Provide regular sessions with the counsellor to discuss concerns and challenges  

• The classroom teacher should provide individualized attention as much as possible  

12.   The student-athlete should be counseled on the importance of him/her being honest about symptoms that occur as he/she is gradually increasing the day-to-day workload in class. This is not to be considered an excuse to avoid work, nor should the student-athlete be trying to hide symptoms. If a particular kind of assignment or activity brings on symptoms such as headaches, confusion, concentration difficulties, etc., then it is critical that the student-athlete let the teacher know. 

Gradually, the student-athlete will take on more and more of the workload, increasing the amount of concentration as long as there are no recurring symptoms. Eventually he/she will build up to a full workload without any symptoms as the original injury heals. 

By the time the School CMP Leader is prepared to issue a School Clearance to Resume Physical Training the student-athlete should be able to handle a full workload without accommodations. If the student-athlete is still not able to handle the full academic workload then the signing of the clearance should be delayed.

Personal Lifestyle Accommodations To Be Followed by Student-Athlete

13.   The student-athlete will be advised to adhere to some or all of the following suggestions which may address their real needs and challenges while suffering from the symptoms of a concussion.

• If you feel any concussion-like symptoms, let your parent/guardian know immediately;  
    

• Immediately stop what you are doing if any symptoms occur and keep track of what caused the symptoms so that you can monitor what level of pressure or stress triggers those symptoms;  
   

• When you feel up to it, you can engage in light physical activities such as walking, gradually progressing to longer and faster paced walking. Once you feel symptoms, cut back to the duration and pace that did not produce symptoms  
   

• Talk to your guidance counselor and/or classroom teacher if you are feeling overwhelmed  
   

• Don’t try to take on too much. Take it slowly, step-by-step. Do not try to push yourself
   .  

• For the first couple of days you should stay away from computers, cell phones, video games, listening to music, television, reading, and anything else that may put pressure on your brain. Remember that your brain is your central nervous system, so even a simple activity like watching television will require a significant amount of work by your brain and at this time you want to give as much of your brain as possible a chance to rest because you are not quite sure where the damage has occurred.  
   

• DO NOT hide symptoms from your parents/guardians, your teacher, your coach or your guidance counsellor. Your entire future depends on how well you allow your brain to recover from this injury. If something is causing symptoms it means that the healing is still taking place. Let your body do its job. Give it time.  

Clearance to Resume Physical Training
 

14. Clearance to resume a universally-accepted step-by-step progression designed to prepare the way for return to play should never begin until the student-athlete is completely symptom free while at rest.

The School CMP Leader or a School CMP Head Coach will administer subsequent post-injury ImPACT tests as directed by CMP. Once the test results have returned to baseline levels, CMP will so advise the School CMP Leader of the return to baseline.
 
CMP will not be giving an official “clearance to return to physical training” because there is so much that we do not know about the student-athlete. The responsibility that has been taken on by our Consulting Neuropsychologist is to examine the post-injury test results and let the school know when the student-athlete’s scores have returned to baseline levels. This would be a sign that the cognitive functioning has been restored.

This is an important thing to keep in mind. Just because the ImPACT test results have returned to baseline levels, one must not automatically assume that the student-athlete has recovered sufficiently to resume physical exertion. It is a good sign, but it is not an absolute sign. At CMP we feel that the parent/guardian will be in a better position to know when their child is "back to normal". Even the classroom teacher will be in a good position to know if there is still "something going on". 

Nevertheless, the return of the ImPACT results to baseline levels is a significant sign that cognitive functioning has been restored. Until then, it must be assumed that there are still problems going on in the brain.
 
If, in addition to the information from CMP that the baseline scores have returned to the baseline level, the School CMP Leader is also waiting to receive each of the following;

            >  Medical Clearance to Resume Physical Training from the treating physician:
            >  Parental Clearance to Resume Physical Training from the student-athlete’s parent;
            >  Written confirmation from the student-athlete that he/she is symptom free;

>  A satisfactory written or oral report from the classroom teacher and/or guidance counsellor;
 

And if the School CMP Leader is completely satisfied him/herself that the student-athlete has recovered sufficiently from the concussion; he/she may then issue a School Clearance to Resume Physical Training and give this clearance form to the School CMP Head Coach.
 
It is to be clearly understood that the School CMP Leader has the final say in whether or not a student- athlete may begin physical training. The School CMP Leader may hold back on this clearance for any reason

Step-By-Step Physical Training Program

15.   Once the School CMP Head Coach receives the School Clearance to Resume Physical Training from the School CMP Leader, the Coach will start the student-athlete on a physical training program that will include a gradual step by step progression designed to eventually prepare the student-athlete for a return to full contact practice and competition.

The supervised training will consist of light aerobic exercises such as walking or stationary cycling that gradually increases in length and resistance. 

If there is no recurrence of symptoms, then this will progress into sport-specific training, such as skating in hockey; running in soccer, etc. At this stage you should be working on the specific skills that will be needed in your sport. 

If no symptoms return while performing the sport-specific skills, you can progress into non-contact training drills. This can be done with teammates who understand that under no circumstances are you to be involved in contact, whether that contact be accidental or deliberate. This is extremely important for your team to know and accept.
 
The Parent/Guardian will play a role in this physical training program and will monitor their child for any signs that symptoms are returning. Home observation is critical at this point because the child may actually be reluctant to report any symptoms to the coach.
 
If the Student-Athlete experiences any symptoms while going through the step-by-step progression, he/she will be required to return at least one step until the symptoms disappear. At no time should the student-athlete be engaging in any activity that brings on symptoms.
 
Each of the preceding steps should take at least one day to complete. This is not a time to rush into things since a return of symptoms could easily occur and seriously delay recovery.
 

School Clearance to Resume Athletic Competition

16.   If the School CMP Head Coach, the Parent/Guardian and the student-athlete are satisfied that the step-by-step progression has been successful and there has been no return of concussion-like symptoms during the training, then the School CMP Head Coach will meet with the School CMP Leader and may then recommend that the student-athlete is ready to return to full contact practice and competition.
 

17. If the School CMP Leader accepts the recommendation, he/she will issue a School Clearance to Resume Athletic Competition and the student-athlete will be permitted to return to full contact practice and competition.  
 

18.  The School CMP Coach will then supervise full-contact practice drills, gradually getting the student-athlete back into game shape and experiencing game-conditions. At this point the decision to get into competition will be up to the coach. Everything should be good to go, but if the School CMP Coach feels uncomfortable, then the student-athlete should be kept out of game situations longer. For example, the student-athlete's first game back should not be against a rival team that has a reputation for being overly aggressive and physical.

CONTINUAL MONITORING OF THE STUDENT-ATHLETE

Due to the fact that people who suffer one concussion are more susceptible to repeat concussions, the student-athlete will be carefully monitored by “all partners” for any further incidents that may cause another concussion.