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Athletic Concussion Regulations


Section I: What is a Concussion? 

A concussion is defined as a transient alteration in brain function without structural damage, but with other potentially serious long-term ramifications. In the event of a concussion, the brain sustains damage at a microscopic level in which cells and cell membranes are torn and stretched. The damage to these cells also disrupts the brain at a chemical level, as well as causing restricted blood flow to the damaged areas of the brain, thereby disrupting brain function. A concussion, therefore, is a disruption in how the brain works; it is not a structural injury. Concussions are difficult to diagnose because the damage cannot be seen. A MRI or CT Scan cannot diagnose a concussion, but they can help rule out a more serious brain injury to a student athlete. Because concussions are difficult to detect, student athletes must obtain medical approval before returning to athletics following a concussion. 

Section II: Mechanism of Injury 

A concussion is caused by a bump, blow or jolt to the head or body. Any force that causes the brain to bounce around or twist within the skull can cause a concussion. A bump, blow or jolt to the head or body can be caused by either indirect or direct trauma. The two direct mechanisms of injury are coup-type and contrecoup-type. Coup-type injury is when the head is stationary and struck by a moving object such as another player’s helmet, a ball, or sport implement, causing brain injury at the location of impact. Contrecoup-type injury occurs when the head is moving and makes contact with an immovable or slowly moving object as a result of deceleration, causing brain injury away from the sight of impact. Indirect forces are transmitted through the spine and jaw or blows to the thorax that whip the head while the neck muscles are relaxed. Understanding the way in which an injury occurred is vital in understanding and having a watchful eye for athletes who may exhibit symptoms of a concussion so these student athletes can receive the appropriate care. 

Section III. Signs and Symptoms 

Signs (what you see): 

● Confusion 

● Forgets plays 

● Unsure about game, score, opponent 

● Altered coordination 

● Balance problems 

● Personality change 

● Slow response to questions 

● Forgets events prior to injury (retrograde amnesia) 

● Forgets events after injury (anterograde amnesia) 

● Loss of consciousness (any duration) 

Symptoms (reported by athlete): 

● Headache 

● Fatigue 

● Nausea or vomiting 

● Double vision/ blurry vision 

● Sensitivity to light (photophobia) 

● Sensitivity to noise (tinnitus) 



● Feels sluggish 

● Feels foggy 

● Problems concentrating 

● Problems remembering 

● Trouble with sleeping/ excess sleep 

● Dizziness 

● Sadness 

● Seeing stars 

● Vacant stare/ glassy eyed 

● Nervousness 

● Irritability 

● Inappropriate emotions 

If any of the above signs or symptoms are observed after a suspected blow to the head, jaw, spine or body, they may be indicative of a concussion and the student athlete must be removed from play immediately and not allowed to return until cleared by an appropriate allied health professional. 

Section IV: Management and Referral Guidelines 

1. When an athlete loses consciousness for any reason, the athletic trainer will start the EAP (Emergency Action Plan) by activating EMS; check ABC’s (airway, breathing, circulation); stabilize the cervical spine; and transport the injured athlete to the appropriate hospital via ambulance. If the athletic trainer is not available, the coach should immediately call EMS, check ABCs and not move the athlete until help arrives. 

2. Any athlete who is removed from the competition or event and begins to develop signs and symptoms of a worsening brain injury will be transported to the hospital immediately in accordance with the EAP. Worsening signs and symptoms requiring immediate physician referral include but not limited to: 

● Amnesia lasting longer than 15 minutes 

● Deterioration in neurological function 

● Decreasing level of consciousness 

● Decrease or irregularity of respiration 

● Decrease or irregularity in pulse 

● Increase in blood pressure 

● Unequal, dilated, or unreactive pupils 

● Cranial nerve deficits 

● Any signs or symptoms of associated injuries, spine or skull fracture, or bleeding ● Mental-status changes: lethargy, difficulty maintaining arousal, confusion, agitation ● Seizure activity 

● Vomiting/ worsening headache 

● Motor deficits subsequent to initial on-field assessment 

● Sensory deficits subsequent to initial on-field assessment 

● Balance deficits subsequent to initial on-field assessment 

● Cranial nerve deficits subsequent to initial on-field assessment 

● Post-Concussion symptoms worsen 

3. After a student athlete sustains a concussion, the athletic trainer will assess and document the student athlete’s concussion. The athlete will not be allowed to continue practice or return to play in the game. 



4. Any athlete who is symptomatic but stable is allowed to go home with his/her/their parent(s)/guardian(s) or parent’s designee following the head injury. 

A. If the head injury occurs at practice, parent(s)/guardian(s) will be notified and appropriate communication will take place between the certified athletic trainer, coach and parent. B. If the injury occurs at a game or event the student athlete may go home with the parent/guardian(s) or parent’s designee after talking with the certified athletic trainer or appropriate medical personnel covering the event. 

C. Parent(s)/guardian(s) will receive important information regarding signs and symptoms of deteriorating brain injury/function prompting immediate referral to a local emergency room. This information will be either given verbally or by a written handout or the parents will be redirected to the CDC website. 

V: Impact Test Protocol 

1. Student athletes, will take a baseline ImPact Test (or other approved test identified by the School District) in the 7th, 9th and 11th grade. The ImPact Test is a tool that helps manage concussions, determine recovery from injury, and is helpful in providing proper communication between coaches, parents and clinicians. The ImPact Test is a neurocognitive test that helps measure student athletes’ symptoms, as well as test verbal and visual memory, processing speed and reaction time. 

2. Each student athlete will complete a baseline test at the beginning of their sport season if their baseline test is expired. Student athletes will be re-tested every other year. If a student athlete plays more than one sport during the academic year, their test will remain valid. For example, if a soccer student athlete also plays basketball in the winter, the student athlete will not have to take the ImPact Baseline Test again in the winter. 

Documentation of Physical Examination: 

All student athletes must have an annual physical examination prior to participating in interscholastic athletics. The completed and signed copy of the physical exam must be mailed, faxed or delivered to the athletic training room office prior to the start of tryouts. A signed doctor’s note will not be accepted, only a physical examination. All physicals are current for 13 months from the date of the physical examination. Any student athlete who does not have a current physical on file with the athletic training office, prior to the first day of tryouts and during the season, is not eligible until a new/updated physical is turned in. It is the student’s responsibility to hand in a current copy of the new physical before it expires. 

Reporting of Prior Head Injury: 

Both the law and regulations require student athletes and their parents to provide an accurate history of head injury to the school prior to each athletic season. On the athletics registration and permission form is a section for reporting prior head injury. This history should include dates, durations of symptoms and time away from physical activity. The athletics registration and permission form will be reviewed by the certified athletic trainer. The athletic trainer will then communicate with the coach regarding the student’s concussion history and discuss any concerns if necessary. 

Hopkinton High School and Middle School Concussion Protocol: 

If an athlete is suspected of having sustained a concussion or MTBI (Mild Traumatic Brain Injury) he or she will be removed from competition immediately and will not be released into their respective 3


sport until they have been cleared by a physician, or those individuals authorized by 105CMR 201.011(A). The ultimate return to play decision is a medical decision that may involve a multidisciplinary approach, including consultation with doctors, a certified athletic trainer, parents, the school nurse and teachers as appropriate. This will be done on a case by case basis. 

In a situation in which a student has been medically cleared but school staff have observed continuing symptoms, the school will make the final decision regarding student’s return to play. If this situation arises, the Hopkinton Public School’s staff should communicate to the physician or health care provider who provided the clearance regarding the symptoms school staff have observed to allow for re-evaluation by the health care provider. It is possible that the health care provider was not aware of the student’s symptoms when the provider gave the clearance. If the athlete still has symptoms, the athlete should not return to play. 

Academic accommodations will be made available if and when deemed necessary pending documentation from a physician. Please see the Post Concussion Academic Accommodation Plan. 

Acute Protocol: 

1. If an athlete sustains a concussion at a home game, he or she will be evaluated by the home certified athletic trainer. If the athlete sustains a concussion at an away game, the athlete will be evaluated by the away certified athletic trainer (if available) and the coach will fill out an accident report. Parents will be notified on both occasions if professional staff (coach or certified athletic trainer) was notified and aware of the concussion. 

2. If the athlete loses consciousness or exhibits severe symptoms, he or she will be transported to the emergency room immediately. 

3. For concussions with no loss of consciousness and less severe symptoms, recommendations will be made to the family and athlete regarding signs and symptoms of a concussion, danger signs to look for, and return to school (24- 48 hours of rest from academics and other cognitive functions) i.e. video gaming, text messaging, computer use, reading. 

4. Recommendations will be made to see a physician. 

5. Certified Athletic Trainer will email the school nurse to inform him/her about the concussion. 6. The school nurse will email the student’s guidance counselor. 

7. The Certified Athletic Trainer will complete the Report of Head Injury form and keep the forms on file in the athletic training room office. 

8. Follow-up testing will occur when asymptomatic (see below). 

Impact Concussion Protocol: 

1. Baseline test: All HHS students will take a baseline impact test in their freshman and junior years. All Middle School students will take a baseline test in 7th grade. 

2. Concussion 

3. Test 1 post injury: After 7 days: IF ASYMPTOMATIC 48 HOURS (or per physician request) a. If test is not within normal reliable change index, retest in 5-7 days. 

b. If test is within normal reliable change index athlete may begin Return to Play protocol. Return to Play Protocol: 

RED: Total physical rest 0-7 days. Take Impact Test if asymptomatic after 7 days of rest. 4


ORANGE: NON IMPACT physical activity, if returned to school full time (time varies) 

a. Exertion (NON IMPACT): 7 days after injury if they are asymptomatic, (bike riding, walking, lifting light weights). If no increase of symptoms, may move onto next phase. 

YELLOW: IMPACT physical activity: (time varies) 

a. Sport Specific (impact): May return to sport specific practice with NO CONTACT (drills, running). If no increase of symptoms, may move on to next phase. 

b. LIGHT CONTACT: 1-2 days: remain asymptomatic 

c. FULL CONTACT: 1-2 days: remain asymptomatic. Athlete must participate in a FULL practice with FULL contact before return to play in a game and remain asymptomatic. 

GREEN: Full participation in a regulation game if asymptomatic and cleared by a physician in conjunction with a certified athletic trainer. 

REMEMBER: All concussions should be progressed as the individual athlete allows. Recurrence of symptoms dictate the rate of moving through the phases. The player may not advance more than one phase in one day. If symptoms return while exercising, the player should return to the previous phase after waiting one day. 

Section VI: School Nurse Responsibilities 

1. Participate and complete the CDC training course on concussions on a yearly basis. 2. Assist in testing all students with baseline and post-injury ImPact testing as needed. 3. Complete symptom assessment when student enters Health Office (HO) with questionable concussion during school hours. 

4. If symptoms are present, notify parent/guardian(s) and instruct parent/guardian(s) that student must be evaluated by an MD. 

(a) If symptoms are not present, the student may return to class and parent will be notified. 5. Allow students who are in recovery to rest in HO when needed. 

6. Develop plan for students regarding pain management. 

7. School nurse will notify teachers and guidance counselors of any students or student athletes who have academic restrictions or modifications related to their concussion. 

8. Educate parents and teachers about the effects of concussion and returning to school and activity. 9. If injury occurs during the school day, inform administrator and complete accident/incident form. 10. Enter physical exam dates and concussion dates into the student information system. 

Section VII: School Responsibilities 

1. Review and, if necessary, revise, the concussion policy every 2 years. 

2. The team will work with the student on organizing work assignments, making up work and giving extra time for assignments and tests/quizzes. 

3. After teachers are made aware of a student’s concussion, they will follow the Academic Post Concussion Accommodation Plan. 



4. Educate staff on the signs and symptoms of concussions and the educational impact concussions may have on students. Teachers will read and follow the Academic Post Concussion Accommodation Plan. 

5. Direct parents with limited English proficiency to the CDC website for educational materials concerning concussions. 

Section VIII: Athletic Director Responsibilities 

1. Provide parents, athletes, coaches, and volunteers with educational training and concussion materials yearly. 

2. Ensure that all educational training programs are completed and recorded. 

3. Ensure that all students meet the physical exam requirements consistent with 105 CMR 200.000 prior to participation in any interscholastic athletic activity. 

4. Ensure that all students participating in interscholastic athletic activity have completed and submitted their pre-participation forms, which include health history form, concussion history form. 

5. Ensure that athletes are prohibited from engaging in any unreasonably dangerous athletic technique that endangers the health or safety of an athlete, including using a helmet or any other sports equipment as a weapon. 

6. Ensure that all head injury forms are completed and are on file. 

7. Inform parent/guardian(s) that, if all necessary forms are not completed, their child will not participate in interscholastic athletics. 

Section IX: Parent/Guardian Responsibilities 

1. Complete concussion history questions on the athletic registration form. 

2. Inform school if student sustains a concussion outside of school hours. Complete new concussion history form following new injury. 

3. If student suffers a concussion outside of school, complete head injury form and return it to the school nurse. 

4. Complete concussion training on the CDC website and check off on the athletic registration form that it was completed 

5. Watch for changes in your child that may indicate that your child does have a concussion or that your child’s concussion may be worsening. Report to a physician: 

● Loss of consciousness 

● Headache 

● Dizziness 

● Lethargy 

● Difficultly concentrating 

● Balance problems 

● Answering questions slowly 

● Difficulty recalling events 

● Repeating questions 

● Irritability 

● Sadness 

● Emotionality 

● Nervousness 

● Difficulty with sleeping 

6. Encourage your child to follow concussion protocol. 



7. Enforce restrictions on rest, electronics and screen time. 

8. Reinforce recovery plan. 

9. Request a contact person from the school with whom you may communicate about your child’s progress and academic needs. 

10. Observe and monitor your child for any physical or emotional changes. 

11. Request to extend make up time for work if necessary. 

12. Recognize that your child will be excluded from participation in any interscholastic athletic event if all forms are not completed and on file with the athletic department. 

Section X: Student and Student Athlete Responsibilities 

1. Complete Baseline ImPact Test prior to participation in athletics. 

2. Report concussion history prior to participation in athletics. 

3. Participate in all concussion training and education and check off that the training was completed on the CDC website. 

4. Report all symptoms to athletic trainer and/ or school nurse. 

5. Follow recovery plan. 

6. REST 



9. Keep strict limits on screen time and electronics. 

10. Don’t carry books or backpacks that are too heavy. 

11. Tell your teachers if you are having difficulty with your classwork. 

12. See the school nurse for pain management. 

13. Return to sports only when cleared by physician and the athletic trainer. 

14. Follow Gradual Return to Play Guidelines. 

15. Report any symptoms to the athletic trainer and/or school nurse and parent(s)/guardian(s) if any occur after return to play. 

16. Return medical clearance form to athletic trainer prior to return to play. 

17. Students who do not complete and return all required trainings, testing and forms will not be allowed to participate in sports. 

Section XI: Coach & Band Instructor Responsibilities 

1. Participate in Concussion Education Course offered by the National Federation of State High School Associations (NFHS) on a yearly basis. Complete certificate of completion and return to the athletic department. 

2. Complete an accident report form if their player suffers a head injury and the athletic trainer is not present at the athletic event. This form must be shared with the athletic trainer and school nurse. 3. Remove from play any student athlete who exhibits signs and symptoms of a concussion. 4. Do not allow student athletes to return to play until cleared by a physician and athletic trainer. 5. Follow Gradual Return to Play Guidelines. 

6. Refer any student athlete with returned signs and symptoms back to athletic trainer. 7. Any coach, band instructor, or volunteer coach for extracurricular activities shall not encourage or permit a student participating in the activity to engage in any unreasonably dangerous athletic technique that unnecessarily endangers the health of a student athlete, including using a musical instrument, helmet or any other sports equipment as a weapon. 

Section XII: Post Concussion Syndrome 



Post Concussion Syndrome is a poorly understood condition that occurs after a student athlete receives a concussion. Student athletes who receive concussions can have symptoms that last a few days to a few months, and even up to a full year, until their neurocognitive function returns to normal. Therefore, all school personnel must pay attention to and closely observe all student athletes for post concussion syndrome and its symptoms. Student athletes who are still suffering from concussion symptoms are not ready to return to play. The signs and symptoms of post concussion syndrome are: 

● Dizziness 

● Headache with exertion 

● Tinnitus (ringing in the ears) 

● Fatigue 

● Irritability 

● Frustration 

● Difficulty in coping with daily stress 

● Impaired memory or concentration 

● Eating and sleeping disorders 

● Behavioral changes 

● Decreases in academic performance 

● Depression 

● Visual disturbances 

Section XIII: Second Impact Syndrome 

Second impact syndrome is a serious medical emergency and a result of an athlete returning to play and competition too soon following a concussion. Second impact syndrome occurs because of rapid brain swelling and herniation of the brain after a second head injury that occurs before the symptoms of a previous head injury have been resolved. The second impact that a student athlete may receive may only be a minor blow to the head or it may not even involve a hit to the head. A blow to the chest or back may create enough force to snap the athlete’s head and send acceleration/deceleration forces to an already compromised brain.The resulting symptoms occur because of a disruption of the brain’s blood auto-regulatory system which leads to swelling of the brain, increasing intracranial pressure and herniation. 

After a second impact a student athlete usually does not become unconscious, but appears to be dazed. The student athlete may remain standing and be able to leave the field under his/her/their own power. Within fifteen seconds to several minutes, the athlete’s condition worsens rapidly, with dilated pupils, loss of eye movement, loss of consciousness leading to coma and respiratory failure. The best way to handle second impact syndrome is to prevent it from occurring altogether. All student athletes who incur a concussion must not return to play until they are asymptomatic and cleared by an appropriate health care professional. 

Section XIV: Concussion Education 

It is extremely important to educate coaches, athletes and the community about concussions. On a yearly basis, all coaches must complete the online course called “Concussion In Sports: What You Need to Know”. This course is offered by the National Federation of State High School Associations (NFHS). Student athletes also need to understand the importance of reporting a concussion to their coaches, parents, athletic trainer and other school personnel. Every year student athletes and parents will 



participate in educational training on concussions and complete a certificate of completion. This training may include: 

● CDC Heads-Up Video Training, or 

● Training provided by the school district 

The school district may also offer seminars, speakers, and discussion panels on the topic of concussions. Seminars offer an opportunity for the certified athletic trainer, athletic director and nurse leader to speak about concussions on the field at practices and games and to discuss the protocol and policy that the district has enacted. Providing education within the community will offer the residents and parents of athletes an opportunity to ask questions and voice their concerns on the topic of brain injury and concussions. When it comes to concussions, everyone needs to be aware of the potential dangers and remember that a concussion is a brain injury. Whenever anyone has a doubt about a student athlete with a concussion, SIT THEM OUT and have them see the appropriate healthcare professional! 



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