Concussion Management for Coaches – What’s Your Game Plan?

What's Your Game Plan?

by James K. Wright, MD

"If I had a concussion, I wouldn't tell the coach because he would take me out of the game." "I'm not even sure what a concussion is." "I've played with concussions before. What's the big deal?" Sound familiar? These comments are what some high school athletes think about concussion. This youthful bravado usually vanishes when a team member's life is permanently changed by the effects of concussion and brain injury. Then there are the parents who want their children to play at any cost, even compromising their well being. And on the other side is a growing group of parents who no longer want their children participating in contact sports because of the danger of brain injury. It's hard enough trying to mold a team, foster athletic skills, and win games - how are coaches expected to stay on top of all the concussion and brain injury stuff and still do their jobs? Fortunately there are a lot of helps for coaches available and I'll try to present them in a manageable way so coaches can be prepared for the school year with a good concussion management plan.

The Concussion Management Plan
Components of a good concussion management plan are:

1. A clear school policy for dealing with and managing students with concussion
2. Education for athletes, parents, assistant coaches, trainers, school officials and local medical professionals.
3. Pre-season baseline neuropsychiatric testing
4. A concussion management policy for players with concussion
5. Awareness and utilization of support services for concussion
6. A good working relationship and understanding with local medical professionals caring for athletes with concussion

Concussion Policy
Schools, districts, athletic association, and states are now developing comprehensive policies for concussion management. Several states have adopted a version of the Washington State Zakery Lystedt Law. Zakery was a middle school football player who suffered a severe brain injury as a result of a concussion on the playing field. The State of Washington passed legislation which has served as a model for several other states for concussion policy. The components of the policy are:

1. yearly mandatory concussion education for student athletes and parents or guardians with a signed "contract" understanding concussion policy and education prior to the athletic season
2. any athlete suspected of sustaining a concussion must be removed from play
3. athlete can only be returned to play after being cleared by a licensed medical professional trained and experienced in the management of concussion
4. liability protection for coaches and schools

The beauty of this type of legislation is that it applies to all student athletes, regardless of age, involved in school sports. In some states the law also applies to private schools, associations, clubs and other organizations using school property. The consistency in application of concussion policy is a great educational experience for parents and students. In time, every parent and athlete should become well versed on concussion management.

Concussion Education
Some excellent educational materials for coaches, students and families are available from the Center for Disease Control (CDC). (http://www.cdc.gov/concussion/sports/resources.html) The materials are free by mail or downloadable and the CDC site offers free training on line as well. Printed materials, videos, slide shows, and podcasts are available specifically designed for students, parents, coaches and school officials. Several excellent materials are also available from the Brain Injury Association of America (http://www.biausa.org/Default.aspx?SiteSearchID=1192&ID=/search-results.htm) which include fact sheets and management materials. Materials and help are also available from your state Brain Injury Association at http://www.biausa.org/state-affiliates.htm.

Baseline Neuropsychiatric Testing
The military, professional teams, college teams and many schools are now using baseline neuropsychiatric testing for athletes. These tests take about 30 minutes, are available online and are inexpensive. The tests establish a baseline for neurocognitive functions such as memory, decision making, processing speed, visual ability and mathematical skills. The testing is valuable because it established a baseline against which an athlete with a suspected concussion can be evaluated. With many concussive events going unreported a brain injury is sometimes only detected because a coach, parent, or friend notices that the athlete is somehow "different," perhaps not sleeping well or too much, irritable, having headaches, or doing poorly in school. While not diagnostic for brain injury, a significantly worse test form the baseline tells us that there is something going on and the athlete deserves further evaluation. One warning – these tests are not meant for use on the sideline or to OK anyone for play with concussion symptoms. They are meant to establish a baseline and identify players who may have a concussion.

A tests such as IMPACT™ (http://www.impacttest.com), and Concussion Vital Signs (http://www.concussionvitalsigns.com/) are available online and costing as little as a few dollars per test. I often hear that schools don't have money for even this. In many communities the local sports medicine clinic, orthopedic surgeons, parents group, or booster club has provided the test for free. The low costs of these tests are also easily within the reach of local fundraising. Don't be afraid to ask – you'll be doing your job as a good coach.

Concussion Management Policy
Let's say you have done all the above and now you are faced with an athlete with a suspected concussion. What do you do? Here are my suggestions:

1. First, let someone else evaluate the athlete. You really don't have time to do this and coach the game or practice. Turn the athlete over to the athletic trainer, assistant coach, or a trained volunteer.
2. Get a good history. Often the concussed player doesn't have a good idea of what happened. Ask other players, officials, or coaches what happened.
3. If the player was knocked out, saw stars was dazed, is confused, has a headache or has amnesia for any length of time remove him or her from play. If unsure, you can administer a sideline concussion screening test such as the King-Devick test (http://kingdevicktest.com). These sideline tests aren't meant to clear athletes for play, but to arouse suspicion of a concussion.
4. Have the player get medical attention and sit out. Return to play is the decision of a medical professional. Most coaches don't want to get into the medical business and the place for concussion assessment is not on the playing field. There also isn't any magic amount of time for clearing concussion symptoms. Every one is different and the important thing is that the athlete is well and cleared for play by a medical professional before coming back to the game or practice.
5. What to expect before athletes can return to the sport - An athlete can return to the sport when all of the following occur:
   • The athlete is symptom free
   • The athlete is symptom free with exercise
   • All testing is normal. This means that any pre season testing neurocognitive testing standards are reached and all medical testing is normal including more advanced neurological testing and scans.
   • The athlete has been cleared to play by a trained medical professional trained and experienced in the management of concussion
   • The parents or legal guardians give permission

This may seem like a lot to ask and you will notice I didn't say any specific amount of time needs to pass before returning to the sport. Setting an arbitrary time for sitting out before returning to practice or play is not good concussion management because every injured brain heals on a different time schedule. Brain healing can take days to years to occur. Every concussion is different and it is important to wait for healing to occur before even considering a return to the sport.

Treatment
We are rapidly moving beyond the old adage of "tincture of time" for brain healing from concussion. If an athlete has persistent symptoms or develops new ones such as sleep disturbances, moodiness, or irritability, known as post concussive syndrome (PCS), there is help. Physical therapy designed to overcome skill deficits and motor problems has advanced considerably. Psychotherapy can improve function at home and school. Education for the athlete and family as well as educators can provide an environment in which athletes with PCS can improve significantly. Early results using hyperbaric oxygen treatment for acute concussion and PCS have been very promising with demonstrable brain healing. Several clinical trials are underway (http://clinicaltrials.gov/ct2/results?term=brain+injury+hyperbaric).

Conclusion
As coaches you have the health and safety of your athletes as one of your chief concerns. By educating everyone involved in school sports on concussion, your concussion management plan, and taking the right steps to implement it on and off the field you can concentrate on the sport while ensuring your team members have the best care available.

James K. Wright, MD, Col, USAF (Ret)
Principal Investigator
National Brain Injury Rescue and Rehabilitation Project
3400 Hannibal St.
Butte, MT 59701