Guidelines forConcussion Managementin the School SettingThe University of the State of New YorkTHE STATE EDUCATION DEPARTMENTOffice of Student Support ServicesAlbany, New York 12234June 2012

ForewordThe Concussion Management and Awareness Act, specifically Chapter 496 of theLaws of 2011, requires the Commissioner of Education, in conjunction with theCommissioner of Health, to promulgate rules and regulations related to students whosustain a concussion, also known as a mild traumatic brain injury (MTBI), at school andat any district-sponsored event or related activity. These guidelines for return to schooland certain school activities apply to all public school students who have sustained aconcussion regardless of where the concussion occurred. The law also requires thatschool coaches, physical education teachers, nurses, and certified athletic trainerscomplete a New York State Education Department (NYSED) approved course onconcussions and concussion management every two years. Finally, the law requires thatstudents who sustained, or are suspected to have sustained, a concussion during athleticactivities are to be immediately removed from such activities. Students may not return toathletic activities until they have been symptom-free for a minimum of 24 hours and havebeen evaluated by, and receive written and signed authorization to return to activitiesfrom a licensed physician. Private schools have the option of adopting such policies.Private schools participating in interschool athletics with public school districts shouldcheck with their governing athletic body (e.g., New York State Public High SchoolAthletic Association, NYSPHAA; or Public School Athletic League, PSAL) to see ifcomplying with the Concussion Management and Awareness Act is a condition ofparticipation.The purpose of this document is to provide school district personnel,parents/guardians, students, and private health providers with information on concussionmanagement in school settings. It explains the purpose of a concussion managementprogram in schools and provides guidance for developing an effective program includingplanning, implementation, and follow-up protocols. This will assist in identifying astudent with a potential concussion, and insure that a student who has been diagnosedwith a concussion receives the appropriate care and attention at school to aid in his/herrecovery.When developing concussion management plans, districts will promote anenvironment where reporting signs and symptoms of a concussion is required andimportant. Students should be seen by their primary medical provider for diagnosis, whothen may choose to refer the student to a specialist as needed. If the student does nothave a primary medical provider, district health personnel may assist families in findingone by providing information on local clinics and/or providers along with information onpublic health insurance. Additionally, districts should be cognizant of the variousconstraints that many students’ families face.Although districts may assistparents/guardians with finding an appropriate medical provider, they should not requirestudents to see a district-chosen provider for a fee in order to be cleared to return toathletic activities. Per this law, any evaluation and clearance authorizing a student toreturn to athletic activities must be performed, written, and signed by a licensedphysician. Such written clearance must be sent to school for review by the districtmedical director and is to be kept in the student’s cumulative health record.i

Extra-class periods of physical education (PE) means those sessions organized forinstruction and practice in skills, attitudes, and knowledge through participation inindividual, group, and team activities organized on an intramural, extramural, orinterschool athletic basis to supplement regular physical education class instruction[8NYCRR 135.1(h)]. In extra class activities, the district medical director is the finalperson to clear a student to return to such activities [8NYCRR 135.4(c)(7)(i)]. EducationLaw Section 902 requires all public school districts to have a director of school healthservices (commonly referred to as the medical director) who may be either a physician ornurse practitioner. In instances where a school district affiliates itself with a medicalpractice for its required health and welfare services, one physician or nurse practitionerwithin that medical practice is to be designated the medical director. The medicaldirector should be consulted when developing district policies and protocols for healthrelated matters such as concussion management.Every attempt has been made to ensure that the information and resourcescontained in this document reflect best practice in the fields of medicine and nursingpractice. Local educational agencies should review these guidelines with their counsel asnecessary to incorporate the guidance with district policy.ii

THE UNIVERSITY OF THE STATE OF NEW YORKRegents of The UniversityMERRYL H. TISCH, Chancellor, B.A., M.A., Ed.D. .ANTHONY S. BOTTAR, Vice Chancellor, B.A., J.D. .ROBERT M. BENNETT, Chancellor Emeritus, B.A., M.S. .JAMES C. DAWSON, A.A., B.A., M.S., Ph.D. .GERALDINE D. CHAPEY, B.A., M.A., Ed.D. .HARRY PHILLIPS, 3rd, B.A., M.S.F.S. .JAMES R. TALLON, JR., B.A., M.A. .ROGER TILLES, B.A., J.D. .CHARLES R. BENDIT, B.A. .BETTY A. ROSA, B.A., M.S. in Ed., M.S. in Ed., M.Ed., Ed.D. .LESTER W. YOUNG, JR., B.S., M.S., Ed. D. .GardensCHRISTINE D. CEA, B.A., M.A., Ph.D. .WADE S. NORWOOD, B.A. .JAMES O. JACKSON, B.S., M.A., PH.D .KATHLEEN M. CASHIN, B.S., M.S., Ed.D.JAMES E. COTTRELL, B.S., M.D. .T. ANDREW BROWN, B.A., J.D. .New YorkSyracuseTonawandaPlattsburghBelle HarborHartsdaleBinghamtonGreat NeckManhattanBronxOaklandStaten IslandRochesterAlbanyBrooklynNew YorkRochesterCommissioner of EducationPresident of The University of the State of New YorkJOHN B. KING, JR.Executive Deputy CommissionerVALERIE GREYDeputy Commissioner of Education – P-12KENNETH G. SLENTZAssociate Commissioner, Office of Curriculum, Instruction and Field ServicesANITA MURPHYThe State Education Department does not discriminate on the basis of age, color, religion, creed, disability,marital status, veteran status, national origin, race, gender, genetic predisposition or carrier status, or sexualorientation in its educational programs, services and activities. Portions of this publication can be madeavailable in a variety of formats, including braille, large print or audio tape, upon request. Inquiriesconcerning this policy of nondiscrimination should be directed to the Department’s Office for Diversity,Ethics, and Access, Room 530, Education Building, Albany, NY 12234. Requests for additional copies ofthis publication may be made by contacting the Publications Sales Desk, Room 319, Education Building,Albany, NY 12234.iii

AcknowledgementsThese guidelines were developed with the assistance of an advisory group consistingof the following participants:Judith Avner, Esq.Executive Director,Brain Injury Association of New York State.Robert Duarte, MDDirector of North Shore Long Island Jewish Health SystemConcussion CenterAssistant Professor of Neurology at Hofstra,NSLIJ Medical SchoolDirector, Pain Institute, Cushing's Neuroscience Institute,NSLIJ Health SystemHelen Hines Farrell, MPAGrant Project Coordinator TBI Implementation GrantHealth Resources and Services AdministrationNew York State Department of HealthLinda BakstDeputy Director of Policy ServicesNew York State School Boards AssociationJeffrey J. Bazarian, MD, MPHAssociate Professor of Emergency MedicineUniversity of Rochester School of Medicine and DentistryMaria Fletcher, RN, PhD, CNEPresident, NYS PTAAlbany, NYKyle McCauley Belokopitsky, Esq.Assistant Director for Governmental RelationsNYS Council of School SuperintendentsEileen M. Franko, MS, Dr.P.H.DirectorBureau of Occupational HealthNew York State Department of HealthAndrew Getzin, MDCayuga Medical CenterSports Medicine and Athletic PerformanceBrian J. Blyth, MDAssistant ProfessorDepartment of Emergency Medicineand Center for Neural Development and DiseaseUniversity of Rochester Medical CenterKaren Cofino, RN, BSN, NCSNNY State Association of School Nurses-PresidentMamaroneck UFSD-School NurseKaren Hollowood, RN, BSN, MSEdAssociate in School NursingStudent Support ServicesNew York State Education DepartmentJune Janssen, RNSouthern Cayuga Central School DistrictPast Treasurer NYSASNBy-Laws/OG Chair NYSASNDarryl Daily, MSEdAssociate in School Health EducationInterim Associate in Physical EducationStudent Support ServicesNew York State Education DepartmentCynthia DiLaura Devore, MD, MA, MS, FAAPChair, Committee on School Health and Sports Medicine,District II, American Academy of PediatricsRobert J. Jones, ATC, M. Ed.Certified Athletic Trainer/Health Educator / Physical Education TeacherQueensbury Union Free School DistrictBarry D. Jordan, MD, MPHDirector, Brain Injury ProgramBurke Rehabilitation HospitalAnthony N. Donatelli Jr., MD, FAAFP, D-ABFMPrivate Practice, School PhysicianSection XI Athletic Safety CommitteeKathleen M. Doyle, Ph.D.Executive SecretaryState Boards for Psychology, Massage Therapy,Clinical Laboratory TechnologyPsychoanalysis/Psychotherapy Review UnitOffice of ProfessionsNew York State Education DepartmentMarilyn A. Kacica, MD, M.P.H., F.A.A.PMedical DirectorDivision of Family HealthNew York State Department of Healthiv

Linda Khalil, RN, BSN, MSEdDirectorNew York Statewide School Health Services CenterMartha Morrissey, RN, BS, MAAssociate in School NursingStudent Support ServicesNew York State Education DepartmentChristopher A. Kus, MD, MPHAssociate Medical DirectorDivision of Family HealthNYS Department of HealthTodd NelsonAssistant DirectorNew York State Public High School Athletic AssociationJennifer M. Kwon, MDAssociate Professor, Neurology and PediatricsAssociate Director, Clinic for Inherited Metabolic DisordersGolisano Children's Hospital at Strong Memorial HospitalUniversity of Rochester Medical CenterPaul Novak, MS, OTRDirector, Neuro-Rehabilitation InstituteSunnyview Rehabilitation HospitalPaul Lasinski, ATC, MACertified Athletic Trainer / Health EducatorHarborfields Central School DistrictLaurene O’Brien, MS, RNInterim Executive SecretaryNew York State Board for NursingOffice of ProfessionsNew York State Education DepartmentJohn Leddy, MD, FACSM, FACPMedical Director, University at BuffaloConcussion Management ClinicUniversity Sports MedicineSUNY Buffalo School of Medicine and Biomedical SciencesWalter Ramos, RN, J.D.Executive SecretaryNYS Board for Medicine,Veterinary Medicine, Dietetics and Nutrition,Athletic Training and Medical PhysicsOffice of ProfessionsNew York State Education DepartmentJoan P. Libby, BS PE, MA, CASDirector of PE, Health & AthleticsBallston Spa Central School DistrictMary Schworm, RN, M.EdSchool NurseMonroe High SchoolRochester City School DistrictErin MatoonStudentLinda Seaman, MSEdAssociate in Education Improvement ServicesStudent Support ServicesNew York State Education DepartmentJason M Matuszak, MD, FAAFPDirector, Sports Concussion CenterChief, Sports MedicineExcelsior OrthopaedicsKenneth Shapiro, MDMedical Director, Brain Injury ProgramSunnyview Rehabilitation HospitalJames McLaughlinStudentNina Van ErkExecutive DirectorNew York State Public High School Athletic AssociationGail Wold, RN, BSNCoordinatorNew York Statewide School Health Services Centerv

Table of ContentsConcussion Overview .1Policy and Protocol Development .2Prevention and Safety .3Identification .5Diagnosis.7Post-Concussion Management.9Return to School Activities .11Guidelines for the Concussion Management Team .12Student .14Parent/Guardian .15School Administrator/Pupil Personnel Staff .16Medical Director .17Private Medical Provider/ Specialists .18School Nurse .19Director of Physical Education and/or Athletic Director .21Certified Athletic Trainer .22Physical Education Teacher/ Coaches .24Teacher .26Resources .28vi

Concussion OverviewConcussions, a type of traumatic brain injury (TBI), are injuries to the brain thatoccur as the result of a fall, motor vehicle accident, or any other activity that results in animpact to the head or body.According to the Centers for Disease Control and Prevention (CDC), Morbidity andMortality Weekly Report (MMWR) [October 7, 2011/ 60(39); 1337-1342]: An estimated 2,651,581 million people under age 19 sustain a head injuryannually.In New York State for 2009: Approximately 50,500 children under the age of 19 visited the emergency roomfor traumatic brain injury and of those, approximately 3,000 were hospitalized.A concussion is a reaction by the brain to a jolt or force that can be transmitted tothe head by an impact or blow occurring anywhere on the body. Essentially, aconcussion results from the brain moving back and forth or twisting rapidly inside theskull. The symptoms of a concussion result from a temporary change in the brain’sfunction. In most cases, the symptoms of a concussion generally resolve over a shortperiod of time; however in some cases symptoms can last for weeks or longer. In a smallnumber of cases, or in cases of re-injury during the recovery phase, permanent braininjury is possible. Children and adolescents are more susceptible to concussions and takelonger than adults to fully recover. Therefore, it is imperative that any student who issuspected of having sustained a concussion be immediately removed from athleticactivity (e.g., recess, PE class, sports) and remain out of athletic activities until evaluatedand cleared to return to athletic activity by a physician.Last updatedJanuary 20141

Policy and Protocol DevelopmentLocal boards of education are strongly advised to develop a written concussionmanagement policy. This policy should reference the district’s protocols, writtencollaboratively with the district medical director to give direction to staff involved in theidentification of a potential concussion. These policies and protocols assist a student whowill return to school and need accommodations after being diagnosed with a concussion.Policies should provide clear protocols, but permit accommodations for individualstudent needs, as determined by the student’s medical provider and/or district medicaldirector.The New York State Education Department (NYSED) and the New York StateDepartment of Health (DOH) recommend the following be included in a district’s policyon concussion management: A commitment to implement strategies that reduce the risk of head injuries in theschool setting and during district sponsored events. A specific list of preventativestrategies should be included in a guidance document appended to the boardpolicy. A procedure and treatment plan developed by the district medical director andother licensed health professionals employed by the district, to be utilized bydistrict staff who may respond to a person with a head injury. The procedure andtreatment plan should be appended to the board policy. A procedure to ensure that school nurses, certified athletic trainers, physicaleducation teachers, and coaches have completed the NYSED-approved, requiredtraining course (See Guidelines for the Team beginning on page 12 for eachprofession). Additionally, the policy should address the education needs ofteachers and other appropriate staff, students, and parents/guardians, as needed. A procedure for a coordinated communication plan among appropriate staff toensure that private provider orders for post-concussion management areimplemented and followed. A procedure for periodic review of the concussion management policy.Last updatedJanuary 20142

Prevention and SafetyProtecting students from head injuries is one of the most important ways toprevent a concussion. Although the risk of a concussion may always be present withcertain types of activities, in order to minimize the risk, districts should insure that (whereappropriate) education, proper equipment, and supervision to minimize the risk isprovided to district staff, students, and parents/guardians. Instruction should includesigns and symptoms of concussions, how such injuries occur, and possible long termeffects resulting from such injury. It is imperative that students know the symptoms of aconcussion and to inform appropriate personnel, even if they believe they have sustainedthe mildest of concussions. This information should be reviewed periodically withstudent athletes throughout each season. Emphasis must be placed on the need formedical evaluation should such an injury occur to prevent persisting symptoms of aconcussion, and following the guidelines for return to school and activities. Providingsupporting written material is advisable. Additionally, the Concussion Management andAwareness Act requires that consent forms (required for participation in interscholasticathletics) contain information on concussions and/or reference how to obtain informationon concussions from the NYSED and DOH websites. It is extremely important that allstudents be made aware of the importance of reporting any symptoms of a concussion totheir parent/guardian and/or appropriate district staff. District staff members must followdistrict emergency protocols and procedures for any student reporting signs andsymptoms of injury or illness.Activities that present a higher than average risk for concussions include, but arenot limited to: interscholastic athletics, extramural activities, physical education classes,and recess. Districts should evaluate the physical design of their facilities and theiremergency safety plans to identify potential risks for falls or other injuries. Recessshould include adult supervision, with all playground equipment in good repair, and playsurfaces composed of approved child safety materials.Physical education programs should include plans that emphasize safety practices.Lessons on the need for safety equipment should be taught, along with the correct use ofsuch equipment. In addition, rules of play should be reviewed prior to taking part in thephysical activity and enforced throughout the duration thereof.Commissioner’s regulation §135.4(c)(4) requires that each school districtoperating a high school employ a director of physical education who shall havecertification in physical education and administrative and supervisory service. Suchdirector shall provide leadership and supervision for the class instruction, intramuralactivities, and interschool athletic competition in the total physical education program.Where there are extenuating circumstances, a member of the physical education staff maybe designated for such responsibilities, upon approval of the Commissioner. Schooldistricts may share the services of a director of physical education.It is recommended that the physical education (PE) director and/or the athleticdirector (AD) of a school district insure that all interscholastic athletic competition rulesLast updatedJanuary 20143

are followed, appropriate safety equipment is used, and rules of sportsmanship areenforced. PE directors should instruct and encourage PE teachers, coaches, and studentathletes from initiating contact to another player with their head or to the head of anotherplayer. Players should be proactively instructed on sport-specific safe body alignmentand encouraged to be aware of what is going on around them. These practices willreduce the number of unexpected body hits that may result in a concussion and/or neckinjury. In addition, proper instruction should include the rules of the sport, definingunsportsmanlike like conduct, and enforcing penalties for deliberate violations.Last updatedJanuary 20144

IdentificationAny student who is observed to, or is suspected of, suffering a significant blow tothe head, has fallen from any height, or collides hard with another person or object, mayhave sustained a concussion. Symptoms of a concussion may appear immediately, maybecome evident in a few hours, or evolve and worsen over a few days. Concussions mayoccur at places other than school. Therefore, district staff members who observe astudent displaying signs and/or symptoms of a concussion, or learn of a head injury fromthe student, should have the student accompanied to the school nurse. If there isn’t aschool nurse, or he/she is unavailable, the school should contact the parent/guardian. Inaccordance with the Concussion Management and Awareness Act, any student suspectedof having a concussion either based on the disclosure of a head injury, observed orreported symptoms, or by sustaining a significant blow to the head or body must beremoved from athletic activity and/or physical activities (e.g., PE class, recess), andobserved until an evaluation can be completed by a medical provider. Symptoms of aconcussion include, but are not necessarily limited to: Amnesia (e.g. decreased or absent memory of events prior to or immediately afterthe injury, or difficulty retaining new information)Confusion or appearing dazedHeadache or head pressureLoss of consciousnessBalance difficulty or dizziness, or clumsy movementsDouble or blurry visionSensitivity to light and/or soundNausea, vomiting, and/or loss of appetiteIrritability, sadness or other changes in personalityFeeling sluggish, foggy, groggy, or lightheadedConcentration or focusing problemsSlowed reaction times, drowsinessFatigue and/or sleep issues (e.g. sleeping more or less than usual)Students who develop any of the following signs, or if the above listed symptomsworsen, must be seen and evaluated immediately at the nearest hospital emergency room: Headaches that worsenSeizuresLooks drowsy and/or cannot be awakenedRepeated vomitingSlurred speechUnable to recognize people or placesWeakness or numbing in arms or legs, facial droopingUnsteady gaitDilated or pinpoint pupils, or change in pupil size of one eyeSignificant irritabilityLast updatedJanuary 20145

Any loss of consciousnessSuspicion of skull fracture: blood draining from ear, or clear fluid from noseDistricts may choose to allow school staff who are appropriate licensed healthprofessionals, and credentialed to use validated neurocognitive computerized testingconcussion assessment tools such as Impact (Immediate Post Concussion Assessment &Cognitive Testing), CogSport (also known as Axon), Headminders, and ANAM(Automated Neuropsychological Assessment Metrics); to obtain baseline and postconcussion performance data. Districts may also choose to allow trained staff to usesideline assessment tools such as SCAT-2 (Sport Concussion Assessment Tool 2), SAC(Standardized Assessment of Concussion), or BESS (Balance Error Scoring System).When choosing to use assessment tests and tools, it is important that districts arecognizant of credentialing requirements of assessors, required testing conditions, alongwith conditions and time intervals required for post-concussion testing. The schooldistrict should seek authorization from the parent/guardian prior to the testing.Additionally, parents/guardians should be given a copy of the results.Neurocognitive computerized tests and sideline assessments may assist districtstaff in determining the severity of a student’s symptoms. They are not a replacementfor a medical evaluation to diagnose a concussion. All students with a suspectedconcussion are to be seen as soon as possible by one of the following medical providers:a physician, nurse practitioner, or physician assistant. Results from assessment tools ortests completed at school should be provided to medical providers to aid in the diagnosisand treatment of students. Students removed from athletic activities at school for asuspected concussion must be evaluated by and receive written and signed authorizationfrom a physician in order to return to athletic activities in school.Last updatedJanuary 20146

DiagnosisIn New York State, the diagnosis of a concussion remains within the scope ofpractice of the following medical providers: physicians, nurse practitioners, and physicianassistants. As part of their licensure, these medical providers are encouraged to remaincurrent on best practices in their fields. Medical providers who are not familiar withcurrent best practice on concussion management are encouraged to seek out professionaldevelopment updates. This section provides a general overview of current best practiceto familiarize district health professionals, and should not be utilized as a replacement forprofessional development.It cannot be emphasized enough that any student suspected of having aconcussion – either based on the disclosure of a head injury, observed or reportedsymptoms, or by sustaining a significant blow to the head or body – must be removedfrom athletic activity and/or physical activities (e.g. PE class, recess), and observed untilan evaluation can be completed by a medical provider. In accordance with theConcussion Management and Awareness Act, a student diagnosed with a concussion isnot to be returned to athletic activities until at least 24 hours have passed withoutsymptoms and the student has been assessed and cleared by a medical provider to begin agraduated return to activities. Per this statute, students removed from athletic activities atschool for a suspected concussion must be evaluated by, and receive written and signedauthorization from, a physician in order to return to athletic activities in school.Evaluation by a medical provider of a student suspected of having a concussionshould include a thorough health history and a detailed account of the injury. TheCenters for Disease Control and Prevention (CDC) recommends that physicians, nursepractitioners, and physician assistants use the Acute Concussion Evaluation Form (ACE)to conduct an initial evaluation. fThe CDC recommends evaluation of three areas: Characteristics of the injury Type and severity of cognitive and physical symptoms Risk factors that may prolong recoveryInjury CharacteristicsThe student, and/or the parent/guardian or district staff member who observed theinjury, should be asked about the following as part of an initial evaluation: Description of the injuryCause of the injuryStudent’s memory before and after the injuryIf any loss of consciousness occurredPhysical pains and/or soreness directly after injuryLast updatedJanuary 20147

SymptomsStudents should be assessed for symptoms of a concussion including, but notlimited to, those listed in the Identification Section on page 5.Risk Factors to RecoveryAccording to the CDC’s Heads Up, Facts for Physicians About Mild TraumaticBrain Injury (MTBI, students with these conditions are at a higher risk for prolongedrecovery from a df/Facts for Physicians booklet-a.pdf History of concussion, especially if currently recovering from an earlierconcussionPersonal and/or family history of migraine headachesHistory of learning disabilities or developmental disordersHistory of depression, anxiety, or mood disordersStudents, whose symptoms worsen or generally show no reduction after 7-14days, or sooner depending on symptom severity, should be considered for referral to aneuropsychologist, neurologist, physiatrist, or

New York State Board for Nursing Office of Professions New York State Education Department John Leddy, MD, FACSM, FACP Medical Director, University at Buffalo Concussion Management Clinic University Sports Medicine SUNY Buffalo School of Medicine and Biomedical Sciences Walter Ramos, RN, J.D. Executive Secretary NYS Board for Medicine,