H.D Jacobs High School

Concussion Cover page

Action/Step Date ATC Initials

Evaluation

Parent Info

Name:_________________

Phone # _______________

Physician Visit

Name:

ImPACT baseline Y/N Normal post-injury:

Step 1: Bike

Step 2: Running

Step 3: Agility/Sports Specific

exercises

Step 4: Non-contact practice

Step 5: Contact Practice

Cleared for RTP

Comments____________________________________________________________________

Athletic Trainer ______________________________________ Date:______________

SCAT5 #: _____________

Examiner:____________

Name: ___________ _______ _________ _______________

DOB: ____________________________ _________ ______

Parent Name/Phone #: _______________________________________ _________

School/Sport: ____________________________ ________

Current Grade: ___________________________ ________

Gender: M / F / Other

Dominant Hand: Left / Neither / Right

How many diagnosed concussion has the athlete had in the past? ____________________ _____ __________

When was the most recent concussion? ________________________________________

How long was the recovery time (time to being cleared to play) from the most recent concussion? __________________________ ( days / weeks )

SCAT5 #: ___________ __

Examiner:____________

Attention parents/ guardians:

Unfortunately your child has sustained a head injury/ concussion the following packet has been put together to provide you

with all the information regarding the next steps in the concussion policy.

Pages 1-2: General information regarding concussion and the return to play process. This info packet provides a brief

overview into the symptoms of concussion and general recommendations for recovery that will be expanded upon by the

physician you see.

Page 3: The first page with the D300 logo. IHSA policy and Illinois Law mandates that each athlete treated for a concussion

must be seen by a physician. This D300 form goes to the physician visit and needs to be filled out by the physician and

returned to the nurse’s office. You are welcome to take your child to any physician of your choosing however I have listed 3

doctors I know personally who treat pediatric concussions and are aware of our concussion policy and protocol.

Dr. Matthew Brandon

455 Briargate Drive, Suite 100

South Elgin, IL 60177

Phone: 847-622-0506

Dr. Jim Krcik

Mercyhealth Crystal Lake

415 Congress Parkway

Crystal Lake, IL 60014

Phone: 815-356-7494

Dr. Pradeep Raju OrthoIllinois 650 S. Randall Rd Algonquin IL 60102 Phone: 779.771.7000

*If you decide to call one of these physicians please make sure to let them know your child is an athlete at Jacobs High School that way they can get you in the office sooner. Page 4: Our return to play protocol. This protocol is a 5-day gradual increase in activity to return the athlete to their perspective sport in a safe manner. This is not optional it is a school policy. Please bring this outline to the physician office so they know what your child will be doing once cleared to return to sport. Page 5: IHSA Return to Sport Form: Please have the athlete and parent/guardian sign the return to sport form and return it to Maddox Reed, athletic trainer so that the return to sport procedure may be initiated once given clearance by physician. Please feel free to call or email me at any time I understand this is a tough process and a scary injury please allow me to answer and questions or concerns. Thank you,

Maddox Reed, MS, ATC, LAT

Head Athletic Trainer - Jacobs High School Affiliate of ATI Physical Therapy Cell: 313-586-2490 email: maddox.reed@atipt.com

During today’s practice/game participation your student-athlete sustained a head injury that requires vital monitoring, and

presents with concussion-like symptoms. Below is a list of signs and symptoms that can occur after sustaining such an

injury. Symptoms may show up immediately following the injury or in some cases several hours later. If any of the signs

and symptoms listed below present the athlete should seek immediate medical attention. If you are questioning whether to

seek medical attention, it is recommended that you do so immediately.

The following signs and symptoms (complaints) mandate immediate emergency room evaluation:

*Headaches that significantly worsen *Looks very drowsy/can’t be awakened *Neck pain

*Can’t recognize people or places *Repeated vomiting *Seizures

*Increasing confusion or irritability *Unusual behavioral change *Focal neurologic signs

*Change in state of consciousness *Weakness or numbness in arms/legs *Slurred Speech

*Blood or watery fluid from ears or nose *Unequal or dilated pupils *Asymmetry of the face

General Recommendations:

Rest is the key. Do not participate in ANY activities if any signs or symptoms exist. Be sure to get enough sleep

at night – no late nights. Take naps or rest breaks as needed.

It is important to limit activities that require a lot of thinking or concentration (called cognitive rest), as this can

make signs and symptoms worse, which may prolong healing. This includes but is not limited to: texting,

operating a computer, watching television, playing video games and reading.

With ANY injury, a full recovery will reduce the chances of getting hurt again. Second-Impact Syndrome is

VERY serious. It is better to miss a few games than to be severely injured for your season, or indefinitely.

Consult with an athletic trainer as available, or see a physician licensed to practice medicine who is familiar with

current concussion care and management as soon as possible for proper evaluation and treatment.

Return to Participation:

As adopted from the National Federation of High School Sports recommendations: After suffering a concussion, no athlete should

return to play or practice on that same day. Newer studies have shown that the young brain does not recover quickly enough for an

athlete to return to activity in such a short time.

Remember: Please realize head injuries and the study of Mild Traumatic Brain Injury (MTBI), also known as concussion, is continually evolving. ATI Physical

Therapy strives to use the most-up-to-date information. If you experience signs or symptoms that vary from the above mentioned ones err on the side of caution and

seek further medical attention from a qualified healthcare provider.

Sources:

- “Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport Held in Zurich, November 2012.” Br J Sports Med,

2013;47:250-258.

- National Federation of High Schools (NFHS) Sports Medicine Advisory Committee (SMAC) Guidelines can be found at: http://www.nfhs.org/content.aspx?id=3325

- Illinois High School Association (IHSA) Sports Medicine Advisory Committee (SMAC) Policy & Resources can be found at:

http://www.ihsa.org/initiatives/sportsMedicine/concussion/index.htm

- National Athletic Training Association Resource Page can be found at: http://www.nata.org/health-issues/concussion

Date:_______

Dear Treating Physician,

Your Patient ___________________________________ is a CUSD 300 student and was injured with symptoms indicating a possible

concussion. A baseline ImPACT test was completed and a post ImPACT test will be given once the student is symptom free for 24

hours and is fully active cognitively.

History: ____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

_______________________________________________________________

Symptoms (Place an X next to all present symptoms):

Symptom Yes No Symptom Yes No

Headache Confusion

Dizziness (Eyes Open) Blurred Vision

Dizziness (Eyes Closed) Sleep Disturbances

Nausea Memory Loss (Anterograde)

Fatigue Memory Loss (Retrograde)

Irritable Pain

Sensitivity to Light Loss of Consciousness

Sensitivity to Sound Other:

Diagnoses:

______ Concussion _______ Head Trauma ________ No Injury

CUSD 300 recognizes the impact of a concussion and supports full cognitive and physical rest.

Please circle the Return to Learn step you prescribe for your patient to begin:

Step Intensity Cognitive Activity Suggested

Accommodations

1 No Activity, No

School

Rest

2 Begin

Accommodated

School Days

-Allow accommodations for symptoms

-1/2 day of school or to allow to rest in nurses office

-All classwork done at home at 30 minute intervals

3 Full day of

school with

Accommodations

-Allow accommodations for symptoms

-Attend all classes but rest in nurses if symptomatic

-Begin classwork as symptoms permit

-Athlete will take post injury ImPACT Test

4 Students return to

full cognitive

activity

-Full day of school

-Full classwork and resume physical education

Athletes will complete the return to play protocol

Please check all that apply:

__________ CUSD 300 must contact you to progress with Return to Learn and Return to Play protocols.

__________ CUSD 300 can progress with the Return to Learn / Return to Play steps as symptoms dictate, but student must be

evaluated by your office before full release.

__________ Once the Return to Learn and Return to Play protocols are completed, patient can be released to full cognitive and

physical activity. CUSD 300 will contact you when patient is released (no further visit necessary).

Contact Information and Signature:

___________________ ________________________ __________________________

Print Physician Name Physician Signature or Stamp Office Phone Number and Email

*Please show to physician

Jacobs High School Protocol for Return to Play after a Head Injury

After an athlete has been evaluated by an athletic trainer and it has been determined that the athlete has sustained a concussion, the following protocol will be used to safely progress their return to play.

Under no circumstances will this protocol be accelerated. There should be approximately 24 hours (or longer) for each stage, and the athlete should return to previous stages if symptoms recur. Resistance

training should only be added in later stages.

Rehabilitation Stage Functional Exercise at Each Stage of

Rehabilitation Success Goal of Each Stage

I . No activity Complete physical and mental rest Recovery (symptom free at rest

2. Biking

Stationary cycling keeping intensity

<70% maximum predicted heart rate

30 min. max

Increase heart rate without symptoms

3. Running

Running while keeping intensity <70% maximum predicted heart rate (30 min. max

Add movement without symptoms

4. Agility Exercises Sport-specific exercises. No head-impact activities.

Add coordination and cognition without symptoms

5. Non-contact practice

Full practice without contact Increase exercise, coordination, and cognitive load without symptoms

May start progressive resistance training

6. Full contact practice Following medical clearance participate in normal training activities

Restore confidence and assess functional skills by coaching staff without s m toms

7. Return to play Normal game play

Protocol established from: 'Consensus statement on concussion in sport - The 3rd International Conference on concussion in sport. held in Zurich, November 2008." Journal of Clinical Neuroscience. (2009) 16:755—763

Return to Participation: It is determined that an athlete is able to return to play when they are symptom free

at rest and at exertion, and have returned to a baseline state of any of the tests they were administered. An athlete will not return to participation the same day as a concussive event. When returning athletes to play,

they will follow the stepwise symptom-limited program outlined above. Once the athlete has received clearance from a physician licensed in all branches, and the athletic trainer, they may return to play. If an

athlete receives clearance from a physician, the athletic trainer still reserves the right to hold the athlete out

of participation. A parent's consent is not a sufficient means for an athlete to return to participation. Athletes who have not been cleared to participate cannot be in uniform for any games.

This protocol is implemented to promote compliance with: IHSA Return to Play Policy, IHSA Protocol for Implementation of NFHS Sports Playing

Rule for Concussions, Illinois HB 0200, and •City of Chicago Ordinance — Concussion Injuries in Student Athletes in Chicago Schools (Ch. 7-22

Municipal Code of Chicago) which outline that athletes exhibiting symptoms of a concussion cannot return to play until cleared by an appropriate

health care professional.

Post-concussion Consent Form

(RTP/RTL)

Date

Student’s Name Year in School 9 10 11 12

By signing below, I acknowledge the following:

1. I have been informed concerning and consent to my student’s participating in returning to play in accordance with the return-to-play and return-to-learn protocols established by Illinois State law;

2. I understand the risks associated with my student returning to play and returning to learn and will comply with any ongoing requirements in the return-to-play and return-to-learn protocols established by Illinois State law;

3. And I consent to the disclosure to appropriate persons, consistent with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), of the treating physician’s or athletic trainer’s written

statement, and, if any, the return-to-play and return-to-learn recommendations of the treating physician or the

athletic trainer, as the case may be.

Student’s Signature

Parent/Guardian’s Name

Parent/Guardian/s Signature

For School Use only

Written statement is included with this consent from treating physician or athletic trainer working under the supervision of a physician that indicates, in the individual’s professional judgement, it is safe for the student to return-to-play and return-to-learn.

Cleared for RTL Cleared for RTP

Date Date _____________________________