Queensborough Community College

Introduction
The Queensborough Community College Sports Medicine Staff will follow specific and evidence-based guidelines for proper concussion management including pre-season and continuing education, return to learn, and return to play following sports related concussion, under the following concussion safety protocol.  The QCC Sports Medicine Staff is committed to providing the highest quality of health care for the student-athletes with sport-related head injuries.
 
The following team members will understand and acknowledge the QCC Athletics Concussion Protocol:
 
Team Physician:  Alexander Volpi, MD (ProHealth)
Athletic Trainer:  Ivan Mak, ATC
Director of Health Services:  Isabel Hocevar, RN
Director of Athletics:  Jon Hochberg, MA
Student-Athletic Academic Advisor:  Hector Blaise, MBA
 
1. Definition of Concussion
A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Also known as a mild traumatic brain injury (mTBI), a concussion is a change in brain function following this force. This may or may not be accompanied by temporary loss of consciousness but is identified in wake individuals with neurologic and cognitive dysfunction. Resolution of symptoms typically follows a sequential course; however, it is important to note that in a small percentage of cases, post-concussive symptoms may be prolonged.

Second-Impact Syndrome
Second-impact syndrome occurs when the brain swells rapidly, and often, catastrophically, after a person suffers a second concussion before the symptoms of an earlier one has subsided. When an individual sustains a ‘second impact’, the brain loses its ability to auto regulate intracranial and cerebral profusion pressures. This loss of regulation leads to rapid swelling, and in some cases, brain herniation. The second concussion can occur minutes, days, or weeks after the initial, and though rare, even the mildest of impact can lead to second-impact syndrome.

Overview
In order to protect the student-athlete’s health when participating in intercollegiate sports at Queensborough Community College, this concussion management policy will be followed in the event of a head trauma. The components of this policy are designed to:

• Provide concussion education
• Establish a baseline health assessment prior to participation
• Outline a plan of action in the event of a head injury
• Outline a stepwise return-to-learn, and return-to-play criteria

 
2. Independent Medical Care
Without the clearance of both the Athletic Trainer and the Athletics Director, a student-athlete may not return to participating in all team activities.  A note from any MD clearing the student to participate will not suffice until the clearance is assessed by the Athletic Trainer and/or the Athletics Director.
 
3. Education (Pre-Season and Continuous Education)
With the use of this concussion protocol, the QCC Sports Medicine Staff will better educate the student-athletes and administration on the dangers and risks of head injuries including concussion.

• QCC coaches will be educated, and they accept the responsibility for reporting suspected head injuries and illnesses to the Sports Medicine Staff, including signs and symptoms of concussions. Coaches will be presented with educational material on concussions.
• The QCC Athletic Trainer and the Team Physician along with the Sports Medicine team of other conference schools will annually meet to discuss changes of EAP and protocol, as needed.
• The entire process, from initial evaluation to final return to play decision, will be documented and placed in the student-athlete’s medical record.

4. Pre-Participation Assessment and Baseline Testing Tools
Pre-participation assessment (baseline testing) will be done via the Sway Medical app which will consist of:
 

• Brain injury/concussion history
• History of neurological disorder
• Mental health symptoms/disorders
• Balance testing
• Cognitive assessment

 
These one-time baseline tests will establish a specific measure for each student-athlete in which concussion diagnosis and return-to-play decisions can be made.
Ultimately, the Athletic Trainer has the final say in pre-participation clearance and/or the need for additional consultation or testing. When student-athletes return at the start of a new academic year, those who have sustained a concussion within the past academic year must be re-baselined prior to any athletic participation.  Baseline tests will last for 2 years from the date it was performed.
 
5. Acute/Immediate Evaluation and Plan of Action
Any student-athlete suspected of sustaining a concussion will be immediately removed from play and evaluated by a member of the Sports Medicine Staff. This includes any student-athlete who is experiencing signs, symptoms, or behaviors consistent with a concussion, whether at rest or with exertion.
Initial evaluation of a suspected concussion will consist of a clinical assessment for cervical spine trauma, skull fracture, intracranial bleed, and catastrophic injury. The Sway post-trauma testing will be performed if student is coherent and responsive.
In the event that a student-athlete is diagnosed with a concussion, or a concussion is unable to be ruled out, they will be withheld from all athletic activity for the remainder of the day. A plan of action will be determined by the Sports Medicine Staff using the components below. This will include, but is not limited to:

• Injury involving significant symptoms, long duration of symptoms, or difficulties with cognitive function
• Deciding on referral to a physician and/or emergency department
• Additional observation, if necessary
• Return-to-learn and return-to-play criteria and progression

Any student-athlete who does not require immediate emergency medical attention, but is diagnosed with a concussion, will be sent home with Home Care Instructions.
 
6. Post-Concussion Management
Initial physical, and relative cognitive rest is a paramount component of an individualized treatment plan for sport-related concussion management. This initial management is based on a series of clinical assessments, concussion history, modifying factors, and specific needs of the student-athlete. Such management includes, but is not limited to:

• Clinical evaluation at the time of injury. When rapid assessment of concussion is necessary (e.g., during competition), symptom assessment, physical, neurological, and balance exams should be performed at a minimum.
• Assessment for head, and cervical spine injury and implementation of emergency action plan as needed.
• Transportation to the nearest hospital if any of the following signs and symptoms are present:
  • Glasgow Coma score less than 13 during initial assessment, or less than 15 at 2 hours or more post initial assessment
  • Loss of consciousness
  • Focal neurological deficit
  • Repetitive vomiting
  • Persistently diminished or worsening mental status
  • Potential spine injury
• Serial evaluation (Sway Medical) and monitoring for deterioration following injury
  • As needed throughout the course of injury, the student-athlete will be evaluated further by the Team Physician. In the event that there is an atypical presentation, or recovery is prolonged (symptomatic for 1 week or longer). This will be done to consider additional diagnoses, best management options, and consideration for further referral. If a student-athlete has suffered multiple concussions within a calendar year, follow-up with a physician will be required.

7. Commuting Considerations
Since QCC is a commuter school, it is important to consider the risks and potential symptom exacerbating stimuli that commuting can have on a concussed individual. Rapid eye movements, such as those required when driving, are well documented to cause immediate increases in symptoms. Similarly, any environment where external stimuli is changing rapidly (i.e., on a subway, train, car) can cause an increase in symptoms.
Considerations for commuting will be taken into account on a case-by-case basis by the Sports Medicine team. The decision for a student-athlete to remain off-campus will be made based on the initial full neurocognitive assessment, as well as subsequent evaluations.
 
8. Return to Learn
Overview
Return to academics, otherwise known as return-to-learn, guidelines assume that both physical and cognitive activities require brain energy utilization. After a concussion, brain energy may not be available for physical and cognitive exertion because of a brain energy crisis. Return-to-learn should be managed in a stepwise program that fits the needs of the individual student-athlete, within the context of a multidisciplinary team that includes physicians, athletic trainers, coaches, counselors, administrators, and academic representatives. The recommendations outlined below are evidence-based. Similar to a return-to-play, it is difficult to provide prescriptive recommendations for return-to-learn. The student-athlete may appear physically normal but may be unable to perform as expected due to concussive symptoms.

Stepwise Progression
The Athletic Trainer will be the point-person for the return-to-learn progression. They will work in conjunction with the Student-Athlete Academic Advisor to make any progress decisions.
As with return-to-play, the first step of return-to-learn is relative physical and cognitive rest. Relative cognitive rest involves minimizing cognitive stressors such as schoolwork, video games, reading, texting, and watching television. There should be no classroom activity the same day that the concussion was sustained. The period of time needed to avoid class or homework should be individualized, and the gradual return to academics should be as tolerated and based on the absence of concussion symptoms following cognitive exposure.

If concussive symptoms last for a period of two weeks or greater, curriculum and testing alterations should be considered. The consensus includes if the student-athlete cannot tolerate light cognitive activity, he or she should remain home. Once cognitive activity can be tolerated without the return of symptoms, the individual should return to the classroom, often in graduated increments.

If at any point during the return-to-learn the student-athlete becomes symptomatic, or scores on clinical/cognitive measures decline, the Team Physician should be notified, and the student-athlete’s cognitive activity reassessed by the Sports Medicine Staff. Any recommendations for long-term academic accommodations will come from the Athletics Director and Athletic Trainer and will be coordinated in conjunction with the office of Services for Students with Disabilities. Compliance with the American Disabilities Act (ADA) as amended by the ADA Amendments Act (ADAAA), including all of its regulations and accommodations, will be maintained throughout the duration of a diagnosed concussion and the return-to-learn process.

The extent of academic adjustments needed should be decided by a multidisciplinary team that may include the Team Physician, Athletic Trainer, coach, professors, and/or academic advisor. The level of multidisciplinary involvement will vary on a case-by-case basis. The majority of student- athletes who are concussed will not need a detailed return-to-learn program because full recovery typically occurs within two weeks. For the student-athlete whose academic schedule requires some minor modification in the first one to two weeks following a concussion, adjustments can be made without requiring meaningful curriculum or testing alterations. If any short-term modifications are necessary, the Athletic Trainer and/or Athletics Director will notify the Office of Student Affairs.
 
9. Return-to-Sport Procedure
Overview
Initial management of a concussion is relative physical and cognitive rest. Athletes diagnosed with a concussion must be removed from play, must not return-to-sport for at least one calendar day, and must be evaluated by the Athletic Trainer. All student-athletes will follow this protocol. If a baseline measure is missing, a comparison to established norms will be utilized. Once a concussed athlete has returned to baseline level of symptoms, cognitive function, and balance, the return-to-sport progression can be initiated.
Return-to-Sport Progression

• Step 1 – Return to activities of daily living without symptoms.  Activities include attending class, commuting, etc.  Student-athlete must be asymptomatic for 24 hours after activity prior to advancing to the next step.
• Step 2 – Performing light aerobic exercise such as walking, swimming or riding a stationary bike.  Student-athlete must be asymptomatic for 24 hours after activity prior to advancing to the next step.
• Step 3 – Performing moderate aerobic exercise such as jogging, body weight squats, planks, sit ups and/or pushups with no head impact.    Student-athlete must be asymptomatic for 24 hours after activity prior to advancing to the next step.
• Step 4 – Performing sports-specific, non-contact drills and progressive resistance training.    Student-athlete must be asymptomatic for 24 hours after activity prior to advancing to the next step.
• Step 5 – Participating in a full practice session without restrictions.    Student-athlete must be asymptomatic for 24 hours after activity prior to advancing to the next step.
• Step 6 – Return to competition with clearance by Athletic Trainer or Team Physician.

Each step is separated by 24 hours, and at any point, if the student-athlete becomes symptomatic, or scores on the clinical/cognitive measures decline, the individual should be returned to the previous level of activity. If no further symptoms are observed, he/she will repeat the step at which symptoms occurred until that step can be completed without return of signs or symptoms. Final determination of return-to-sport ultimately resides with the Team Physician/physician designee (Athletic Trainer).

If the student-athlete fails to complete the post-injury evaluations to baseline standard, he/she must wait 24 hours before re-testing. Should the student-athlete fail the post-injury evaluations on the second attempt, he/she must wait 48 hours prior to re-testing. This protocol will be followed for any subsequent evaluations.
Unrestricted return-to-sport will not occur prior to unrestricted return-to-learn for injuries occurring while the student-athlete is enrolled in classes.
Multiple concussions in one season or competition year will be referred to the Team Physician for follow-up and determination of playing status.

Documentation
All diagnosis and testing results will be documented in the student-athlete’s medical file. Documentation will include initial injury evaluations, each subsequent evaluation, and details of progression regarding return-to-learn, and return-to-play.


Updated:  October 8, 2021