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
So
what does all of this mean for school boards and post-secondary
institutions? Well, for one thing, as we learn more and more about
concussions we are finding that repeat concussions are occurring at
alarming rates. This is causing many insurance carriers to
reconsider the risk of providing coverage for this type of injury.
In fact there are some professional leagues that simply cannot get
insurance for athletes who are unable to play because of
concussions. Some are only allowed one concussion per career, and
then after that the team must pick up the full cost of the contract.
We
do not worry about coverage to replace salaries for
student-athletes, but since 50% or more of the student-athletes in
high school will likely have had at least one concussion in their
life, school officials must be concerned about the life-altering
consequences of repeat concussions.
SCHOOL
BOARDS ARE RESPONSIBLE FOR THE SAFETY OF STUDENTS
Provincial
and State legislation imposes upon teachers, principals and school
boards a responsibility to ensure the safety of all students in
their care. This duty of care applies to sport activities as well as
all other activities that are run by the school. If we continue to
encourage a greater participation rate among student-athletes in
school-sponsored sport activities, we need to have written
procedures in place that deal with concussions which are bound to
occur. Since up to 80% of all concussions go unreported, we also
don’t know what kind of true concussion history exists for most
student-athletes, so we may be placing some of our students in grave
danger without knowing it in the first place. That is why a strong
and effective student-athlete concussion management program is more
important now than it has ever been.
INCREASED
KNOWLEDGE MEANS INCREASED DUTY OF CARE STANDARDS
Because
of what we are discovering about the human brain, it won't be long
before the issue of negligence is brought up with school boards,
teachers and coaches when it comes to brain trauma injuries suffered
by student-athletes. At this point we do not see much change in the
risk of being accused of being negligent when it comes to
student-athletes receiving their first concussion. After all, as
long as the coaches have trained the players and have provided a
reasonable level of care, injuries in competition will be treated as
the nature of the game. Anyone who participates in school sports
understands that there is an inherent risk of injury.
However,
when it comes to the return to play of a student-athlete who has
suffered a concussion, we now know a lot more than we knew a few
years ago. We know the potential consequences of returning a player
too soon. The duty of care may rise to a higher standard because of
this. We know that the chance of a repeat concussion is high,
especially if the first concussion didn't have sufficient time to
heal. And since approximately 50% of all student-athletes will have
suffered at least one concussion before the end of high school, if
they were not allowed to rest long enough following the first one,
they are up to four times more likely to have a second concussion.
The
importance of having an effective concussion management program in
place at every secondary school and post-secondary institution is
why it is becoming a legal requirement in many jurisdictions today.
School Boards need to have a specific written protocol in place.
That being said, there are some concussion management protocols that
were developed many years ago and are in need of serious upgrading.
And with the advances that are being made with respect to brain
trauma and concussions, it would be extremely hard for a school
administrator to defend some of these ineffective protocols when
more effective ones were readily available.
Whereas
schools owe student-athletes a duty to take reasonable care not to
knowingly put them in situations where they may be injured or suffer
life-altering consequences that will damage their future, the
Student-Athlete Concussion Management Program that school boards
develop should contain such a comprehensive scope of coverage that
it would be virtually impossible for anyone to claim that the school
was negligent in caring for a student-athlete who has suffered a
concussion.
We
were diligent when formulating the identification and rehabilitation
protocols that have been included in the framework model we
recommend in this CMP Program Guide. We have established so many
safety-nets within the program that there is very little chance of
returning an injured student-athlete to play prematurely. That
doesn't mean that he/she will never get a repeat concussion, but it
certainly shouldn’t be because of the negligence on the part of
the coach or any of the partners involved in the program if our
recommended protocols are adopted.
This
is why we will always recommend clearances from a medical
practitioner and the parent/guardian. It is why school boards should
require an evaluation from a licensed neuropsychologist familiar
with sport-related traumatic brain injuries indicating that the
student's ImPACT results are back to baseline. It is why the
student-athlete him/herself should be expected to sign a declaration
that there are no more known symptoms from the injury. It is why we
strongly recommend a clearance from the School CMP Leader, who will
consult with the child's classroom teachers prior to giving
permission for the student-athlete to return to physical training.
And finally, after all of the above, it is why we recommend that the
School CMP Head Coach review the results of the training program
with the School CMP Leader to get a final clearance to resume
practice with full contact and competition.
It
would be hard for anyone to find the actions of a school which has
incorporated the main elements of the CMP Student-Athlete Concussion
Management Program to be negligent in the care and duty owed to its
students. If anything, a school board will have gone over and above
the requirements that could be imposed by any level of government.
EXPECT
AN INCREASE IN NUMBER OF REPORTED CONCUSSIONS
|
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.
UNIVERSALLY ACCEPTED
PRINCIPLES
|
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. |