June 2017
IDPH
Iowa Department
of
Public Health
Concussion
Management
Guidelines
for Iowa Schools
Contents
1. Purpose ..................................................................................................................................................... 3
2. Introduction .............................................................................................................................................. 4
What is a concussion?............................................................................................................................... 4
Signs and symptoms ................................................................................................................................. 4
Table 1: Concussion signs and symptoms............................................................................................. 4
Prevention................................................................................................................................................. 5
Creating a culture of good concussion management ............................................................................... 5
Establishing a team-based concussion management protocol ................................................................ 5
The concussion management team.......................................................................................................... 6
Table 2: Multi-disciplinary concussion management team .................................................................. 6
3. Implications for Learning – Acute Recovery ............................................................................................. 8
Returning to school after a concussion .................................................................................................... 8
Table 3: Graduated return-to-school strategy (McCrory et al, 2017)................................................... 9
Adjustment versus accommodation....................................................................................................... 10
Classroom adjustments........................................................................................................................... 10
Table 4: Symptom wheel .................................................................................................................... 11
Using symptoms to monitor recovery .................................................................................................... 13
Figure 1: Decision-making flow chart for increasing cognitive demands ........................................... 14
4. Implications for Learning – Prolonged Recovery .................................................................................... 15
5. Return to Activity & Play......................................................................................................................... 15
Reducing the risk of concussion.............................................................................................................. 15
Iowa concussion law and recommended best practice.......................................................................... 16
Table 5: Iowa law and best practice recommendations - concussion education............................... 16
Table 6: Iowa law and best practice recommendations – removal from play and activity................17
Table 7: Iowa law and best practice recommendations – return-to-play and activity....................... 18
Concussion testing .................................................................................................................................. 18
Graduated return-to-play .......................................................................................................................19
Table 8: Graduated return-to-play stages (McCrory et al, 2017) ....................................................... 20
6. Partnering with Families ......................................................................................................................... 21
Creating the culture of concussion awareness....................................................................................... 21
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Supporting the family team .................................................................................................................... 21
7. Providing Collaborative Care after a Concussion.................................................................................... 23
Medical team ..........................................................................................................................................23
Preexisting conditions............................................................................................................................. 24
Information gathering and concussion symptoms .................................................................................24
Navigating HIPAA and FERPA.................................................................................................................. 24
Communication and cross-team collaboration.......................................................................................25
Understanding IDEA and Section 504 of the Rehabilitation Act.............................................................25
Table 9: IDEA and Section 504 Plan crosswalk....................................................................................25
Addressing barriers................................................................................................................................. 26
The role of the school nurse and/or licensed athletic trainer ................................................................ 26
8. Developing a Concussion Management Protocol................................................................................... 27
Getting started........................................................................................................................................ 28
Components of a good concussion management protocol.................................................................... 28
Concussion management process........................................................................................................... 29
Acknowledgements..................................................................................................................................... 34
Appendix A: Resources ...............................................................................................................................35
PRINTABLE MATERIAL............................................................................................................................. 35
WEBSITES ................................................................................................................................................ 35
VIDEOS ....................................................................................................................................................36
APPS (available for free) .........................................................................................................................37
Appendix B: Symptom checklist..................................................................................................................38
Appendix C: Teacher feedback form........................................................................................................... 39
References .................................................................................................................................................. 40
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1. Purpose
On April 7, 2011, Iowa enacted legislation (Code of Iowa 280.13C) for the protection of students
from concussion and other brain injuries. This legislation requires three main brain injury policy
activities:
1) Education on concussion, brain injury identification, and associated risk of participating
in extracurricular activities after suffering a concussion or brain injury;
2) Removal from play for suspected concussion; and
3) Return-to-play after evaluation and written clearance from a health care provider.
Because this law applies to students participating in sports, dance, or cheerleading in seventh
through 12th grades, much of the initial focus for concussion education and management has
been on high school student athletes and their return-to-play. As concussion awareness has
increased, so has the apparent need for consistent and reliable information about the proper
management of concussion for students of all ages, regardless of the cause of their concussion.
In response, a community-based concussion management program authored by Dr. Karen
McAvoy, called REAP (which stands for Remove/Reduce, Educate, Adjust/Accommodate, and
Pace), was adapted in 2016 by the Brain Injury Alliance of Iowa.
The Iowa Departments of Education and Public Health have both endorsed the utilization of
REAP. Concussion Management Guidelines for Iowa Schools builds upon the elements outlined
in the REAP manual. These guidelines include information and resources Iowa schools can
utilize when forming their multi-disciplinary concussion management teams and implementing
concussion management protocols.
A group of experts from across Iowa developed the content in this document. Information was
utilized from publicly available material through the Centers for Disease Control and Prevention
(CDC); Rocky Mountain Hospital for Children – HealthONE; Colorado Department of Education;
and the 5
th
International Conference on Concussion in Sport held in Berlin, October 2016. A list
of these and other references are available at the end of this document.
This information is intended for all Iowa public and non-public accredited schools supporting
learners from pre-K through age 21. The implementation of Concussion Management
Guidelines for Iowa Schools is voluntary and may be used at the discretion of individual schools;
however, the Iowa Departments of Education and Public Health strongly encourage the use of
these guidelines to protect the health and safety of students who sustain a concussion.
The Concussion Management Guidelines for Iowa Schools will be reviewed, at a minimum, every
three years to ensure the content reflects current knowledge and best practices in the field of
youth concussion. Therefore, schools and individuals using this information should verify they
have the most current version of this guide. For further information, including technical
assistance for implementing these guidelines, contact the Iowa Department of Public Health by
calling 515-281-8465 or emailing [email protected].
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2. Introduction
What is a concussion?
Concussions are a type of traumatic brain injury caused by a fall, motor vehicle crash, or other
bump or blow to the head or body. Sometimes an injury resulting in concussion is referred to as
a “ding” or “getting your bell rung,” but what seems to be a mild bump or blow can be very
serious. The student may experience a loss of consciousness; however, most concussions occur
without a loss of consciousness. A concussion can impair not only the physical abilities of a
student, it can also affect how that student thinks, acts, feels, and learns.
Signs and symptoms
Signs and symptoms of concussion can occur immediately after the injury or may not become
apparent until days after the injury. Children and adolescents are more susceptible to
concussions and take longer to recover from their symptoms than adults; however, most
children and adolescents will recover quickly and fully. The typical length of recovery may vary,
with some students’ concussion symptoms lasting for only a few days while others continue to
have symptoms for several weeks or even months. Consequently, symptoms may have short- or
long-term effects on the student.
How a concussion affects a student will vary on a case-by-case basis. Signs and symptoms
generally fall into one of four categories: physical, cognitive, emotional, or sleep/energy.
Examples of signs and symptoms that may be experienced after a concussion are outlined in
Table 1.
Table 1: Concussion signs and symptoms
PHYSICAL
(how a person feels physically)
Headache/pressure
Nausea
Blurred vision
Vomiting
Dizziness
Numbness/Tingling
Ringing in ears
Sensitivity to light
Seeing “stars”
Sensitivity to noise
Vacant stare/Glassy eyed
Disorientation
Neck pain
COGNITIVE
(how a person thinks)
Feel in a “fog”
Easily confused
Feel “slowed down”
Easily distracted
Difficulty remembering
Slowed speech
Difficulty concentrating
Difficulty organizing
EMOTIONAL
(how a person feels emotionally)
Inappropriate emotions
Irritability
Personality change
Sadness
Nervousness/Anxiety
Lack of motivation
Feeling more “emotional”
Argumentative
Easily annoyed
SLEEP/ENERGY
(how a person experiences their energy level
and/or sleep patterns)
Fatigue
Drowsiness
Excess sleep
Sleeping less
Trouble falling asleep
than usual
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Prevention
A concussion is a type of traumatic brain injury. Children and adolescents are especially at risk
of sustaining a concussion when they are active participants in sports and other physical
activities. Therefore, it is important to reduce the risk of concussion from happening by taking
preventive measures. These steps include:
Maintaining a safe school environment through periodic safety reviews of play/sporting
areas to ensure that equipment and surfaces are appropriate, safe, and maintained.
Providing appropriate and adequate supervision for sporting events, field trips, and
recess.
Providing access to properly fitted protective gear designed for the activity.
Implementing and enforcing guidelines for fair rules and appropriate techniques.
Creating a culture of good concussion management
Recognition and the proper response to concussions help to promote recovery and reduce the
risk of further injury, or even death. Iowa’s concussion law mandates specific brain injury
policies for the education of coaches, parents, and athletes about concussion recognition, signs,
and symptoms. After a suspected concussion, the law requires the removal of the student
athlete from play/activity. Once removed, the student athlete can only return to play/activity
with written clearance from a health care professional. In order to create a protocol that is
more comprehensive, schools are encouraged to expand on the minimum standards included in
the law by utilizing the best practice guidelines highlighted in this document.
For more information about Code of Iowa 280.13C and recommended best practices,
see section 5: Return to Activity/Play.
A school with a positive concussion culture is one where youth recognize and report concussion
symptoms so that they can get the support and time needed to recover. This approach includes
providing concussion information, as well as shaping the way concussion is discussed. Coaches,
school staff, and parents should routinely speak to the students, particularly student athletes,
about concussions and the importance of maintaining health and safety. An environment
should be created where students are encouraged to discuss their concerns and questions
about concussion. Students should feel supported in reporting a concussion and removing
themselves from play. Schools should also convey their commitment to support students
returning to learn in the classroom after sustaining a concussion through established protocols
and practices.
Establishing a team-based concussion management protocol
Schools are recommended to have a written concussion management protocol that includes
strategies to educate teachers, staff, students, and parents regarding concussion prevention,
identification, and management. The protocol should outline the school’s plan to support
students returning to learn through appropriate academic adjustments or accommodations, as
well as a graduated return to activity once the student’s concussion symptoms have sufficiently
resolved in the academic setting.
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A key component to successfully supporting a student with concussion symptoms involves the
utilization of a “Concussion Management Team.” This multi-disciplinary team consists of four
sub-groups: the Family Team, School Academic Team, School Physical Team, and Medical Team.
These four teams each have specific roles and responsibilities during the return-to-learn and
return-to-play process and will be referred to throughout this document.
See section 8: Developing a Concussion Management Protocol for more detail about
implementing the concussion management team.
The concussion management team
A multi-disciplinary concussion management team approach is an optimal way to manage a
concussion and to return a student to learning and physical activity. This approach involves
communication and collaboration among the team members throughout the stages of
concussion recovery. The degree of involvement from specific team members may fluctuate
throughout this process, depending on the stage of recovery and the needs of the student.
As stated earlier, the Concussion Management Team consists of four smaller teams, (1) Family
Team; (2) School Academic Team; (3) School Physical Team; and (4) Medical Team. Each team
has an important role in the various stages of concussion recovery, as outlined in the REAP
manual:
The School Physical Team and/or Family Team may be the first to recognize a suspected
concussion and to remove the student from activity.
The Medical Team has a role in diagnosing, managing the concussion, and ruling out a
more serious medical condition.
During the early stages of concussion recovery, the Family Team and School Academic
Team will provide critical management by reducing social, home, and school stimulation
in collaboration with the Medical Team. These teams will lead symptom tracking and
monitoring.
When all four teams decide that the student has recovered to a pre-concussion level of
functioning, the Medical Team can approve a graduated “return-to-play” protocol to be
implemented by the School Physical Team. At this stage, the School Physical Team will
have a lead role in symptom tracking and monitoring.
It is important that the entire team continue to have communication regarding the
student’s progress, and to report any return of symptoms with increases in activity.
When the student successfully completes the “return-to-play” steps, the Medical Team
can determine final clearance. If a student did not access a health care provider, the
parent/guardian may give written permission to return to activity/play.
Table 2: Multi-disciplinary concussion management team
Team
Roles & Responsibilities
Family Team
Remove student from physical activity
immediately, including play at
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home/community, recreational and/or club
sports.
Communicate with school and medical
teams.
Reduce home/social stimulation including
“screen time” such as texting, social media,
video games, and TV. This also includes
reducing or eliminating time spent in loud
environments such as sporting events,
parties, concerts and dances.
Reduce or restrict driving or operating
machinery.
Encourage rest.
Monitor and document emotional and
sleep/energy changes attributed to the
concussion by using a symptom checklist.
Provide information regarding student’s pre-
concussion cognitive functioning to the
Medical and School Teams.
As symptoms lessen, gradually remove home
and activity restrictions, as tolerated.
Medical Team
Remove student from physical activity
immediately.
Rule out more severe medical issues,
including a severe traumatic brain injury.
Consider risk factors and evaluate for
concussion complications.
Support reduction of school demands and
home/social stimulation.
Encourage rest.
Approve graduated return-to-play after
determining student’s concussion symptoms
have resolved and when documentation
indicates the student is performing at pre-
concussion cognitive demand levels at home
and school.
School Academic
Team
Remove student from all physical activity at
school, including PE and recess.
Adjust academic demands (see section 3:
Implications for Learning – Acute Recovery).
Encourage “brain rest” breaks at school.
Monitor and document academic and
emotional effects of the concussion.
Provide information regarding student’s pre-
concussion academic functioning.
Assign an academic “point person.”
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Teachers can gradually increase cognitive
demands or reduce academic adjustments, as
tolerated, using the decision-making flow
chart in Figure 1.
School Physical
Team
Remove student from all physical activity
immediately.
Support reduction of school demands and
home/school stimulation.
Provide encouragement to rest and take the
needed time to heal.
Watch, monitor and track physical symptoms
of the concussion.
Appoint a physical team “point person.”
Monitor the graduated return-to-play steps
after receiving medical approval.
3. Implications for Learning – Acute Recovery
Returning to school after a concussion
It is common for the student, their parents/guardians, or their coaches to wonder when the
student is ready to be cleared to return to sports and other physical activities. However, it is
important to remember that each youth is a student first and an athlete second. This means
that planning for the student to “return-to-learn” is as important as their “return-to-play.”
Following a concussion, it can be difficult for a health care provider to anticipate when the
student will be ready to return to school. It is not necessary for the student to be 100 percent
symptom free before returning to school; many students who have experienced a concussion
can return to the classroom while still experiencing some symptoms related to their injury. A
good rule of thumb is to wait until the student is beginning to tolerate 30-45 minutes of light
cognitive activity. Typically, this should not require more than two or three days of absence
from school, although each case should be managed individually. The goal is to return the
student to the classroom as soon as possible without causing symptoms to worsen. Table 3
outlines a structured return-to-school strategy and the goal of each stage.
Concussions are as unique as the individuals who experience them. This uniqueness includes
the severity and combination of symptoms experienced as well as the rate at which the student
will recover. Open communication between the parent/guardian, student, health care provider,
and school staff will be important for determining how soon the student returns to school and
the extent of academic adjustments required to ensure optimal recovery. To accurately
evaluate the rate of recovery, it is important for post-concussive symptoms to be monitored
carefully. A symptom checklist, such as the one found in Appendix B, should be used to monitor
symptom status and recovery.
Additional information on symptom monitoring, including a recommended frequency of
monitoring, can be found in section 6: Partnering with Families.
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Table 3: Graduated return-to-school strategy (McCrory et al, 2017)
Stage
Goal
Activity
Objective of each
stage
1
Daily activities at home
that do not give the
child symptoms
Typical activities of the child during the day as long
as activities do not increase symptoms (e.g., reading,
texting, screen time). Start with 5-15 minutes at a
time and gradually build up.
Gradual return to typical
activities
2
School activities
Homework, reading or other cognitive activities
outside of the classroom.
Increase tolerance to
cognitive work
3
Return to school part-
time
Gradual introduction of schoolwork. May need to
start with a partial school day or with increased
breaks during the day.
Increase academic
activities
4
Return to school full-
time
Gradually progress to increased school activities
until a full day can be tolerated.
Return to full academic
activities and catch up
on missed work as
needed
Once a concussion has been diagnosed, it is critical to REMOVE the student from physical
activity, including PE/gym classes, active recess, and athletics until the student has been cleared
by their health care provider.
For additional information about how and when to reintroduce physical activity, refer to
the section 5: Return to Activity & Play.
A review by the concussion management team should be conducted promptly to determine the
need for supports, if any. Given the majority of students with a concussion will have their
symptoms resolve within two to three weeks, it may be most efficient to implement many of
the needed classroom adjustments before a formal accommodation plan can be put fully in
place. However, the concussion management team may consider starting conversations about
formalizing a plan for the student so that a seamless transition can occur if additional supports
are needed later on.
Regardless of whether or not supports are formalized, the concussion management team will
be responsible for assuring that everyone supporting the student understands the situation and
their role concerning the safety and well-being of the student. This includes clearly
communicating the following information:
The student's condition.
Implications the symptoms have on learning.
Individualized adjustments and accommodations implemented.
Information/data collection and reporting.
The roles and responsibilities of the various team members.
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More information about setting up the concussion management team and coordinating
the flow of information is available in section 8: Developing a Concussion Management
Protocol.
Adjustment versus accommodation
The terms “adjustment” and “accommodation” are used throughout this document to describe
the various interventions that may be implemented to support the student while they recover
from a concussion. Adjustment is used to describe the informal changes implemented to
support the student. Accommodation describes changes documented in a formalized process
such as a Section 504 Plan or Individualized Education Plan (IEP).
For more information on Section 504 of the Rehabilitation Act, see section 7: Providing
Collaborative Care after Concussion.
Classroom adjustments
Academic adjustments support the student by pacing cognitive demands while recovering from
the concussion. It is up to the school and its teachers, with input from the family and student,
to determine which adjustments to put in place to best support the student’s individualized
needs during this acute recovery stage. The school academic and physical teams will coordinate
the return of the student; therefore, it is important that all adults involved understand the
student’s symptoms and how best to pace cognitive demands.
In Table 4, the “symptom wheel” provides strategies that correspond with specific concerns the
student may experience after a concussion. Although a health care provider may make
recommendations regarding concussion management, a medical order or release is not
required to initiate or modify academic adjustments or accommodations.
To support the student’s concussion recovery process, the majority of adjustments should be
made immediately following the injury and then, as the student’s symptoms begin to resolve,
adjustments can be scaled back simultaneously as cognitive demands are increased. This
approach provides the appropriate amount of cognitive rest while supporting the student’s
academic engagement.
It is acceptable to have the student return to the classroom while they continue to experience
symptoms as long as the symptoms are tolerable, manageable, and/or intermittent.
Adjustments should be implemented in the general education classroom as soon as possible
and be based on the specific symptoms the student is experiencing. However, educators should
recognize that it is not unusual for students to be reluctant to accept adjustments and to try to
“push through” symptoms to complete their assignments. Additionally, younger students may
have a more difficult time explaining their symptoms and identifying their academic needs.
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SLEEP/ENERGY
mentally fatigued
drowsy
sleeping too much
sleeping too little
can't
initiate/maintain
sleep
Table 4: Symptom wheel
PHYSICAL:
Strategic Rest Scheduled 15
to 20 minute breaks in
clinic/quiet space (mid-
morning; mid-afternoon
and/or as needed).
Sunglasses (inside and
outside).
Quiet room/environment,
quiet lunch, quiet recess.
More frequent breaks in
classroom and/or in clinic.
Allow quiet passing in halls.
REMOVE from PE, physical
recess and dance classes
without penalty.
Sit out of music, band and
computer classes if
symptoms are provoked.
EMOTIONAL:
Allow student to have
“signal” to leave room.
Help staff understand that
mental fatigue can
manifest in “emotional
meltdown.”
Allow student to remove
him/herself to de-escalate.
Allow student to visit with
supportive adult
(counselor, nurse, advisor).
Watch for secondary
symptoms of depression
and anxiety usually due to
social isolation and concern
over “make up work” and
slipping grades. These extra
emotional factors can delay
recovery.
Symptom Wheel
Suggested Academic Adjustments
(McAvoy, 2013)
PHYSICAL
COGNITIVE
Headache/sick to
trouble with:
stomach
concentration
Dizziness/balance
problems
remembering
Light
mentally "foggy"
sensitivity/blurred
slowed processing
vision
Noise sensitivitiy
Neck pain
EMOTIONAL
feeling more:
emotional
nervous
sad
angry
irritable
COGNITIVE:
REDUCE workload in the
classroom/homework.
REMOVE non-essential
work.
REDUCE repetition of work
(e.g., only do even
problems; go for quality, not
quantity).
Adjust “due” dates; allow
for extra time.
Allow students to “audit”
classwork.
Exempt/postpone large
test/projects; alternative
testing (quiet testing, one-
on-one testing, oral testing).
Allow demonstration of
learning in alternative
fashion.
Provide written instructions.
Allow for “buddy notes” or
teacher notes, study guides,
word banks.
Allow for technology (tape
recorder, smart pen) if
tolerated.
SLEEP/ENERGY:
Allow for rest breaks-in
classroom or clinic (i.e.
“brain rest breaks” = head
on desk, eyes closed for 5 to
10 minutes).
Allow student to start school
later in the day.
Allow student to leave
school early.
Alternate “mental
challenge” with “mental
rest.”
The student with a concussed brain may not be as efficient in their ability to learn new material;
therefore, cognitive rest is important and applies to both the activities within the classroom as
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well as homework assignments and exams. Not only can it be difficult for the student to convert
the information from working memory into long-term memory, but conceptual learning can be
affected as well. Simply postponing assignments, projects, and exams for later completion is
not recommended. This may create a stockpile of work that exceeds the capacity of the
student’s recovering brain and can create a great amount of anxiety for the student.
The ultimate goal for academic adjustments is that the student will still be able to demonstrate
mastery of learning standards and benchmarks. One method for helping teachers implement
adjustments is to categorize each of the pieces of a lesson plan in one of three ways: (1)
excused work, (2) accountable or negotiable work, or (3) required work. If adjustments that
modify standards and benchmarks are needed, a “Disability Suspected” meeting should be
considered.
“Excused work” includes the in-class and homework assignments or projects that are not
required and do not need to be made up later. “Accountable/negotiable work” includes
content that is required, but for which the process can be modified (e.g., alternate
assignments). Finally, “required work” includes assignments and exams that must be completed
by the student and will be graded.
The following recommendations should be considered when the student is struggling to learn
new information or is not able to fully participate in class:
Determine which material is the most critical for the student to receive and to be held
responsible. Because the learning process is compromised after a concussion, the
teacher must choose which parts of the lesson plan are the most important.
Remove or excuse the student from tests or large projects. Testing while the student is
cognitively compromised may not accurately reflect the student’s skills. This is especially
applicable for high stakes tests and projects.
Standardized tests should be avoided or appropriate testing adjustments should be
provided.
Focus on ensuring the student understands the material rather than requiring rote
memorization of facts.
Remove in-class work and homework that is not essential. It is not practical to expect
the student to make up all the work that was missed or delayed while recovering from a
concussion.
On average, 80 to 90 percent of students with concussions will recover within two to three
weeks. During this time, the student may be able to exert increasing amounts of cognitive
energy each day while symptoms simultaneously become less frequent and severe. Therefore,
academic adjustments should be fluid and flexible based on the progress of the student’s
recovery.
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Using symptoms to monitor recovery
During concussion recovery, the goal is to have the student participate in learning without
exacerbating concussion symptoms. Implementing frequent, objective assessments of the
student’s concussion symptoms is the only way to evaluate the balance between sufficient
academic adjustments and cognitive demands.
As the student improves, tolerance of cognitive demands may be tested by increasing work
amount, difficulty, or time required (only one component should be changed at a time). As
outlined in Figure 1, teachers can base their decision for increasing workload by using symptom
feedback as a guide. If the student does not report a recurrence or increase in concussion
related symptoms when increased demands are implemented, continue to gradually introduce
additional cognitive demands over time. However, if symptoms worsen discontinue the activity
for at least 20 minutes while the student is allowed to rest. If rest provides symptom relief, then
the student can attempt the activity again either at the same or lower demand level that
caused the symptoms. If rest does not relieve the symptoms, the activity should be
discontinued and reattempted later. The health care provider should be updated regarding the
student’s progress during this process, especially in the event the student is not progressing
through the steps for increasing cognitive demands.
The same method can also be used for gradually increasing home, social, and school activities.
As the student begins to experience a decrease in symptoms, their ability to tolerate additional
activities can be tested, with the exception of physical activities. If the activity makes symptoms
worse, stop the activity and try again after the symptoms improve with rest.
A valuable tool for monitoring symptoms is a symptom checklist or rating scale. Monitoring
symptoms provides information used to assess symptoms and to track the student’s symptom
severity and recovery across settings. The symptom checklist or rating scale should be simple
enough to be used by the student, the family, the school, and the health care provider. While it
is important to monitor symptoms at school, the family and student should be monitoring
symptoms at home as well. The full range of symptoms the student has experienced post-injury
should be monitored, including changes in sleep, energy, and emotions. The health care
provider can help to determine which symptoms developed post-injury as a result of the
concussion.
A sample symptom checklist is available in Appendix B.
Communication is vital to ensure optimal recovery from a concussion. Not only is
communication between the family and school critical, but communication is essential among
all members of the concussion management team. This includes sharing updates about the
student’s symptoms as well as any stressors the student is experiencing. Ideally, the monitoring
of symptoms should take place at both school and home. Then, the information collected is
shared across settings and among team members.
A sample teacher feedback form is available in Appendix C.
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Figure 1: Decision-making flow chart for increasing cognitive demands
Just as the process for increasing cognitive demands must be individualized based on the needs
of each student, the frequency of symptom tracking, as well as the type of symptoms that are
monitored, should be determined by the concussion management team. During the first week
of recovery, symptoms may need to be assessed daily, especially to monitor sleep/energy and
emotional symptoms. Frequency of monitoring can be tapered during the subsequent weeks of
recovery, assessing symptoms at least three times a week during the second week of recovery
and at least twice during the third week.
The information gathered should be used to monitor progress and modify adjustments during
the student’s recovery. Information about the student’s progress at school and home is also
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useful for the health care provider when determining recommendations regarding the
graduated return-to-play/activity process. When feasible, a release of information form should
be signed by the student’s parent/guardian to allow direct information sharing between the
school and a health care provider. The school team should identify a person, ideally the school
nurse, to facilitate the communication between the school and the health care provider.
Additional information about setting up these processes can be found in section 7:
Providing Collaborative Care after a Concussion.
4. Implications for Learning – Prolonged Recovery
The majority of students (80 to 90 percent) will have concussion symptoms resolve within two
to three weeks. However, the remaining 10 to 20 percent of students will have ongoing
symptoms that take longer to resolve. For those students who continue to struggle past the
acute recovery phase (four or more weeks), the concussion management team will need to
discuss options for supporting the student through more extensive, or targeted, academic
accommodations. A hierarchy support process may begin with the multi-tiered system of
supports (MTSS). Should a need persist for three months or more, a Section 504 evaluation may
be warranted.
In the event that the student’s concussion impacts their learning for a longer period, or even
permanently, more significant academic modifications may need to be considered and the
student should be evaluated for an Individualized Education Plan (IEP).
More information about Section 504 and IDEA can be found in section 7: Providing
Collaborative Care after Concussion.
5. Return to Activity & Play
Reducing the risk of concussion
As mentioned earlier, children and adolescents are especially at risk of sustaining a concussion
when participating in sports and other physical activities. It is important to reduce the incidence
of concussion by taking preventive measures.
These measures include routinely conducting safety reviews of play/sporting areas to ensure
that equipment and surfaces are safe and well-maintained. Similarly, students of all ages should
have access to, and appropriate fitting of, activity-specific protective gear. Licensed athletic
trainers, when available, are a knowledgeable resource to provide options, proper sizing, and
fitting of protective gear. The CDC has downloadable helmet fact sheets for a variety of
activities, which address proper size and fit as well as care and replacement tips.
A link to CDC materials is included in the resource list found in Appendix A.
An adequate number of appropriately trained individuals should provide supervision for
sporting events, field trips, and recess should be provided at all grade levels. Guidelines for age-
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appropriate, fair rules, and safe techniques should be established, communicated, and
enforced. The Iowa High School Athletic Association and the Iowa Girls’ Athletic Union have
established protocols that can be referenced to establish guidelines for use with younger
students.
A link to the Iowa High School Athletic Association and Iowa Girls’ Athletic Union
concussion page is included in the resource list found in Appendix A.
Iowa concussion law and recommended best practice
Return-to-school does not automatically mean return-to-play. It is essential that the student
has recovered sufficiently from the concussion, meaning the student is able to be free from
concussion symptoms while managing pre-concussion level cognitive demands. For the purpose
of these guidelines, “play” includes not just extracurricular interscholastic activities as defined
by the Code of Iowa 280.13C but also includes physical activity the student may participate in
such as, but not limited to, physical education, dance, sports leagues, and recess.
The 2011 Iowa law outlines specific policies regarding concussion education as well as the
removal and return-to-play of students who have a suspected concussion. Students covered by
the law are those individuals in grades 7 through 12 who are participating in an extracurricular
interscholastic activity. As defined by the law, “extracurricular interscholastic activity” means
“any extracurricular interscholastic activity, contest, or practice, including sports, dance, or
cheerleading.”
In the following tables (5-7), the requirements of the law are outlined along with corresponding
recommendations for best practice. These recommendations are not required by Iowa law, but
should be considered for adoption by schools and applied to all students, not just high school
level student-athletes.
Table 5: Iowa law and best practice recommendations - concussion education
CONCUSSION EDUCATION
Required by Iowa Code 280.13C(1)b
Annually, each school district and nonpublic school shall provide to the parent or guardian of each
student a concussion and brain injury information sheet, as provided by the Iowa High School Athletic
Association (IHSAA) and the Iowa Girls’ High School Athletic Union (IGHSAU). The student and the
student’s parent or guardian shall sign and return the concussion and brain injury information sheet
to the student’s school prior to the student’s participation in any extracurricular interscholastic
activity for grades seven through twelve.
Best Practice Recommendations for Concussion Education
Annual distribution of concussion and brain injury information fact sheet to all students and
parents/guardians, regardless of the student’s grade or participation in extracurricular
interscholastic activity. The IHSAA and IGHSAU currently distribute the CDC’s HEADS UP:
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Concussion in High School Sports fact sheet for parents and students. This document is available
in over 40 languages through your school’s TransACT account.
Annually, the student and their parent/guardian should sign and return the concussion and brain
injury information sheet to the student’s school, prior to participation in any school sponsored
activity/sport for all grades.
Annually, school staff should receive a concussion and brain injury information fact sheet and be
informed of the school’s protocol for concussion management.
Annually, coaches at all levels complete the online concussion training available for free through
NFHSlearn.com. This training is currently required by the Iowa Board of Educational Examiners for
coaches of athletes in grades seven through twelve and recommended by IHSAA and IGHSAU for
all coaches.
Annually, school staff who teach physical education or supervise recess, along with the school
nurse, should complete a concussion training, such as the one available for free through
NFHSlearn.com.
Health education or physical education coursework should incorporate age-appropriate
information on the risk, signs, symptoms and behaviors consistent with a concussion or brain
injury, including the dangers of continuing to participate in activities after sustaining a concussion
or brain injury.
Annually, school staff participating on the concussion management team should receive
concussion and brain injury continuing education.
Table 6: Iowa law and best practice recommendations – removal from play and activity
REMOVAL FROM PLAY and ACTIVITY
Required by Iowa Code 280.13C(2)
If a student’s coach or contest official observes signs, symptoms, or behaviors consistent with a
concussion or brain injury in an extracurricular interscholastic activity, the student shall be
immediately removed from participation.
Best Practice Recommendations for Removal from Play/Activity
If any school employees or contracted staff observes signs, symptoms, or behaviors consistent
with concussion or brain injury during physical activity (e.g. recess, physical education,
extracurricular activities/sports sponsored by the school at any grade level), the student should
be immediately removed from participation.
A responsible adult should remain with the student and continue to monitor for deterioration
during the initial few hours after injury. The student should not be allowed to drive.
The parent/guardian, teacher/s, school nurse, and school administrator should be notified as
soon as possible regarding any student who has been removed from play/activity for a suspected
concussion.
A licensed health care provider should evaluate a student suspected of having a concussion the
same day the injury occurs.
If a student or parent/guardian report to the school an injury resulting in signs, symptoms, or
behaviors consistent with concussion or brain injury, the student should be removed from
participation in physical activities including but not limited to recess, P.E., and sports.
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Begin forming the student’s concussion management team to discuss possible academic
adjustments and monitoring of symptoms.
Table 7: Iowa law and best practice recommendations – return-to-play and activity
RETURN-TO-PLAY (RTP) and ACTIVITY (RTA)
Required by Iowa Code 280.13C(3)a
A student who has been removed from participation shall not recommence such participation until
the student has been evaluated by a licensed health care provider trained in the evaluation and
management of concussions and other brain injuries and the student has received written clearance
to return to participation from the health care provider.
Best Practice Recommendations for RTP/RTA
Any student who has been removed from participation due to suspected concussion should
not be allowed to return to participation in physical activities (e.g., physical recess, physical
education, sports, dance) until evaluated by a license health care provider trained in the
evaluation and management of concussion and other brain injuries.
Students should not return to activity the same day of the suspected concussion.
Students who are exhibiting signs and symptoms consistent with a concussion following an
injury should not be returned to activity/play until they are able to manage pre-injury
cognitive demands without symptoms.
The graduated RTP protocol may begin after the concussion management team has agreed
that the student is symptom-free at pre-concussion cognitive levels. If a health care provider
is involved as part of the concussion management team, written clearance has been provided
to begin RTP.
The RTP protocol should include provisions to delay return-to-play if any signs or symptoms of
concussion return during or after physical activity.
After a suspected concussion occurs, each school should have a process that activates the
concussion management team to provide coordinated communication and timely
documentation. The school must also have a process for documenting the injury, symptom
tracking, and written clearance.
Each school should implement a written concussion management plan applicable to all
students.
The concussion management team should be involved in the evaluation and communication
of returning students to activity/play.
Concussion testing
The IHSAA and IHSGAU have recommended the use of the Sport Concussion Assessment Tool 3
(SCAT3) or Sport Concussion Assessment Tool 5 (SCAT5) as a tool for the sideline evaluation for
possible concussion of injured athletes. Both are standardized tools for medical professionals
to use with students aged 13 years and older. For younger children, ages 12 and under, the
Child SCAT3 and Child SCAT5 are available. The Concussion Recognition Tool 5 is a validated tool
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for use by coaches and parents to aid in determining whether they should remove a student
from an activity and further evaluation is needed.
Links to the SCAT, Child SCAT and the Concussion Recognition Tool are included in the
resources list found in Appendix A.
There are a number of commonly used, commercially available pre- and post-concussion tests
of mental status, orientation, and postural-stability. These assessments are completed by
individuals with the required credentials. Results of any testing or assessment should be shared
with the health care provider and the concussion management team; however, no diagnosis of
concussion or return-to-play decision should be made solely based on concussion cognitive
testing. A student may still have a concussion even if they score in the normal range on a
concussion assessment. Therefore, any test or assessment results should be treated as an
additional report used to inform the concussion management team and healthcare provider.
Conducting a concussion history may identify students who fit a high-risk category. A structured
history may include specific questions about previous symptoms of a concussion and the length
of recovery. Questions assessing the symptom severity relative to severity of impact may also
provide a health care provider with an indication of whether the student may have a
progressively increased vulnerability to injury. This information may be useful in determining
whether a student athlete should “retire” from participation.
Graduated return-to-play
Best practice for concussion management includes ensuring the student being symptom-free
prior to the health care professional approving and monitoring a graduated return-to-play
process (see Table 8). If the student is receiving any concussion-related academic adjustments
related to a concussion, they are not yet ready to return-to-play.
Until recently, it had generally been accepted that following a concussion, complete rest was
recommended until the individual was symptom-free. This belief was based on the idea that
rest may reduce the symptoms during acute recovery and promote recovery by minimizing the
cognitive and physical demands on the brain. Research now shows that light activity can help
individuals recover more quickly and that prolonged rest may have adverse effects. The 2016
Berlin consensus statement includes the following recommendation:
“After a brief period of rest during the acute phase (24-48 hours) after injury, patients
can be encouraged to become gradually and progressively more activity while staying
below their cognitive and physical symptom-exacerbation threshold (i.e., activity level
should not bring on or worsen their symptoms). It is reasonable for athletes to avoid
vigorous exertion while they are recovering.” (McCrory et al, 2017)
The level of activity described above is considered stage one of the graduated return-to-play
process. Returning to play and activity following a concussion is a medical decision that should
include the following decision-making criteria:
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The student is symptom-free at home, interacting with friends and family normally, and
documented symptoms should be at baseline or “0.”
Academic adjustments are no longer required and the student is symptom-free at
school and performing at their pre-concussion levels for schoolwork and during social
activities. This includes the School Academic Team reporting the student’s test scores,
workload, and homework are back to where they were before the concussion, and
teacher observations include the student is no longer exhibiting signs of concussion and
symptom-free when in loud, busy environments such as hallways, assemblies, and
lunchroom.
If applicable, the student’s neurocognitive testing scores are back to baseline.
The licensed athletic trainer, if involved, reports that the student is 100 percent
symptom-free.
The student is no longer taking any concussion-related medications, including over-the-
counter medications used to treat headache or pain related to the concussion.
If the student does not meet the above criteria, they are not ready to begin the graduated
return-to-play steps. Students should not receive final written medical clearance until they have
demonstrated successful completion of all stages of the graduated return-to-play process.
Table 8: Graduated return-to-play stages
(McCrory et al, 2017)
Stage
Activity
Functional exercise at each stage of rehabilitation
Objective of stage
1
Symptom-limited
activity
Daily activities that do not provoke symptoms.
Recovery
When 100% symptom free for 24 hours proceed to Stage 2. (recommend longer symptom-free periods at each
state for younger student/athletes)
2
Light aerobic
exercise
Walking or stationary cycling at slow to medium
pace. No resistance training.
Increase heart rate
If symptoms re-emerge with this level of exertion, then return to the previous stage. If the student remains
symptom free for 24 hours after this level of exertion, then proceed to the next stage.
3
Sport-specific
exercise
Running or skating drills. No head-impact activities.
Add movement
If symptoms re-emerge with this level of exertion, then return to the previous stage. If the student remains
symptom free for 24 hours after this level of exertion, then proceed to the next stage.
4
Non-contact training
drills
Progression to more complex training drills, e.g.
passing drills in football and ice hockey. May start
progressive resistance training.
Exercise, coordination
and increased thinking
If symptoms re-emerge with this level of exertion, then return to the previous stage. If the student remains
symptom free for 24 hours after this level of exertion, then proceed to the next stage.
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5
Full-contact practice
Following medical clearance, participate in normal
training activities.
Restore confidence
and assess functional
skills by coaching staff
If symptoms re-emerge with this level of exertion, then return to the previous stage. If the student remains
symptom free for 24 hours after this level of exertion, then proceed to the next stage.
6
Return-to-play
Normal game play.
No restrictions
6. Partnering with Families
Creating the culture of concussion awareness
Best practice in concussion assessment and response are changing at an increasingly rapid
pace. This has resulted in a broad range of concussion knowledge and practice, much of which
may not have kept up with the pace of this evolving field. Therefore, schools are a critical
access point for engaging students and families by providing current, relevant concussion
information, even before an injury occurs.
All students and their families should receive information about concussion recognition, the
school’s concussion practices, and protocols for preventing and managing concussions.
Information should be made available annually through means such as student/parent
handbook, virtual backpack, Facebook updates, or factsheet distribution. Additionally,
concussion information should be permanently accessible in commonly visited locations such as
the school website or by hanging posters in common areas such as the school lobby,
gymnasium, and school offices.
It is important to develop an environment where all students feel comfortable discussing
concussions and reporting symptoms. Parents and staff should be encouraged to discuss
concussions with the students. Coaches, PE teachers, and others should encourage concussion
reporting and positively reinforce students for doing so. Students should also be praised for
supporting their peer who is sitting out of play after a concussion.
The school should inform students and parents/guardians of the school’s practice and policies
for removal from activity when a concussion is suspected or reported. This is also an
opportunity to provide information to the family about whom to notify if their child sustains a
concussion outside of the academic school day.
Supporting the family team
Once a concussion has been reported, the family becomes a vital part of the concussion
management team. Prior to meeting with the concussion management team, information
should be shared with the family regarding the purpose of the concussion management team,
the importance of their participation, and the school’s “return-to-learn” and “return-to-play”
protocols.
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Education regarding concussion symptoms should be provided to the student and their family.
Students should be encouraged to communicate any symptoms promptly to school staff and a
parent/guardian. A symptom checklist can be used for tracking and reporting symptoms during
a set period of time. Unless there is a specific recommendation from a health care provider for
the frequency of symptom monitoring, symptoms should be checked daily for the first week,
particularly during the first few days. It is critical that symptoms be monitored within the first
48 to 72 hours. Red flag symptoms that indicate the need for immediate medical attention
include vomiting, seizure/convulsion, severe or increasing headache, unusual behavior change,
double vision, complaints of neck pain or weakness or tingling/burning in arms or legs, or
deteriorating conscious state. Symptom monitoring should continue with a frequency of at
least three times during the second week and at least twice a week for the third week.
A sample symptom checklist is available in Appendix B.
The quality and quantity of information provided by the student will depend on the individual’s
age and other factors. Therefore, it is recommended the student:
Be educated about the signs and symptoms, including red flag symptoms, that must be
reported to the coach, licensed athletic trainer, school nurse, parent/guardian, and/or
other staff.
Track and report symptoms, as appropriate.
Follow instructions from their health care provider.
Be encouraged to ask for help and to inform teachers of difficulties experienced in class
and when completing assignments.
The parent/guardian should be involved in the concussion management team as the primary
advocate for their child. When a concussion is reported, it is important that the family
understand the need for communication with both the health care provider and the school. The
family will likely have a number of questions during this time and be concerned about their
child’s well-being; therefore, the school has an important role in educating and engaging the
family. It is recommended that the family:
Be educated about the signs and symptoms of concussion, including when to seek
emergency care.
Help the student understand the importance of accurately reporting their concussion
symptoms.
Be informed regarding the Iowa concussion law and how the law may pertain to their
child.
Be informed of the school’s concussion policies and protocols.
Be made aware of the importance of rest along with the benefits of a gradual return to
pre-injury levels of cognitive and physical activity.
Be encouraged to ask questions and report concerns to their child’s health care provider
and the school as necessary.
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Participate in and/or inform the concussion management team discussions regarding
the level of academic adjustments/accommodations provided by the school.
Consider signing a release of information between the health care provider and the
school nurse (or other member of the School Physical Team).
Participate in and/or inform the concussion management team’s discussion regarding
“return-to-play,” especially if the student has been medically cleared but school/home
reports clearly indicate the student is still symptomatic or is not functioning at pre-injury
levels in the learning environment.
Provide the school with information and medical orders from the health care provider in
a timely manner.
Participate in the tracking and reporting of symptoms their child experiences, including
significant fatigue or other symptoms at the end of the school day.
Monitor their child’s physical and mental health during the transition back to full
activity.
7. Providing Collaborative Care after a Concussion
The initial point of contact for students sustaining a concussion often begins with the health
care provider, school nurse, or licensed athletic trainer. Each licensed or certified professional
plays a key role in the concussion management team to promote the student’s recovery.
Medical team
Students may come into a primary care clinic, urgent care clinic, or emergency department
soon after sustaining a concussion. The recognition and early appropriate management of a
concussion are essential to improving the student’s health care outcomes. Health care
providers play a critical role on the concussion management team. They provide education to
the student and family regarding the typical course of a concussion, symptom management,
and how brain rest promotes positive health outcomes after concussion.
The health care provider may include hospital providers, primary care providers, neurologists,
and others who diagnose concussion routinely in their professional practice. Health care
providers on the medical team experience the challenge of balancing school attendance with
rest and recommending appropriate adjustments to ease cognitive demands, while being
alerted to any increase in symptoms as academic adjustments are gradually removed.
Appropriate adjustments at this stage may be informal changes made to the student’s
academic day or during school-sanctioned activities that do not jeopardize the student’s
curriculum or require alterations in standardized testing. Information collected by the
concussion management team regarding the student’s symptoms at school and home should
be shared with the health care provider, if applicable. The health care provider may use this
information to determine when the student can begin a safe progression back into physical
activity.
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Additional information regarding academic adjustments can be found in section 3:
Implications for Learning - Acute Recovery.
Preexisting conditions
Health care providers understand the importance of reviewing pre-existing conditions with the
student, such as:
Migraines
Attention deficit hyperactivity disorder (ADHD)
Headaches
Visual disorders
Learning disabilities
Motion sickness
Other mental health conditions
For students who have experienced a concussion, preexisting conditions may have an impact on
concussion symptoms or symptom recovery. The health care provider puts together the entire
picture of the student’s health status by uncovering underlying conditions, evaluating
symptoms, and reviewing information regarding the student’s health history. Provider visits and
physical examinations are specifically targeted at identifying known deficits associated with
concussion. The initial management of concussion begins with a recommendation for cognitive
and physical rest, followed by a gradual increase in cognitive and physical activities, depending
on current symptoms and prior history.
Information gathering and concussion symptoms
The medical team asks important questions to collect more information about the student’s
concussion. These may include:
When, where, and how did your injury occur?
Did you experience any symptoms immediately?
Did you visit a health care provider for these symptoms; if so, who was it and where
were you seen?
What symptoms do you currently experience?
What makes these symptoms better or worse?
Are you taking any medications to treat symptoms? Which medications and how often?
Have you noticed any changes in your activity level or tolerance at school? At home?
With electronic devices?
How have you been sleeping at night? Is this a change?
As stated earlier, the medical team relies on communication with the family, the student, the
school physical team, and the school academic team to monitor the student’s recovery after
sustaining a concussion. This information is used to formulate a plan of care for safely returning
to learn and then returning to physical activities.
Navigating HIPAA and FERPA
Health care providers are aware that a student’s health information is private and protected by
the Health Insurance Portability and Accountability Act (HIPAA). Additionally, educational
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records, which include those created by the school nurse or other school personnel, are
protected by the Family Educational Rights and Privacy Act (FERPA). To facilitate open
communication between the medical team and rest of the concussion management team, the
health care provider should obtain a signed release of medical information from the parent or
guardian to communicate with school personnel. The school may also request the parent to
sign a consent to communicate with the health care provider. Valuable information shared
between the medical provider and school related to the student’s concussion includes
symptom tracking and medical findings that can be used to promote implementation of the
concussion management plan. Parents who are not comfortable with the school nurse, licensed
athletic trainer, or academic team communicating directly with the medical team may choose
to facilitate sharing select information with the appropriate team.
Communication and cross-team collaboration
The concussion management team relies on the expertise and collaboration of its members to
problem solve difficulties or concerns that may arise during the student’s concussion recovery.
Communication among the concussion management team members is vital to the success of
implementing a student’s concussion management plan. Periodic updates provided to the
school nurse and the licensed athletic trainer regarding the health services received and follow-
up visits to the medical provider will promote continuity of care between settings. Information
related to the student’s recovery, including the presence or absence of symptoms as well as any
specific modifications or restrictions required, is especially important to share with all school
and medical team members.
The medical team provides the concussion diagnosis and may also use the REAP concussion
management manual to coordinate care with the student’s school or family. With access to
applicable regulations and school policy, the school may benefit from the medical team’s
participation in making appropriate recommendations for both return-to-learn and return-to-
play, including the documentation of needed short-term or long-term supports. Together, the
concussion management team can determine and implement necessary short-term
adjustments. Long-term accommodations, if needed by the student, will require a formalized
plan. This includes obtaining consent for evaluation and following an outlined process
completed by the school academic team. Section 504 of the Rehabilitation Act or the
Individualized Disabilities Education Act (IDEA) are the two formal processes that may be used
to create a customized plan for the student.
Understanding IDEA and Section 504 of the Rehabilitation Act
All members of the concussion management team work together to implement the identified
plan. The objective of this plan is to promote positive health outcomes and academic success
for every student who experiences a concussion.
Table 9: IDEA and Section 504 Plan crosswalk
IDEA (Parts B and C)
Section 504 Plan
Definition in
Law
• Specific disability categories as defined in the
law can include autism, deafness, deaf-
Defines persons with disabilities
who:
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blindness, hearing impairments, intellectual
disability, multiple disabilities, orthopedic
impairments, health impairments, serious
emotional disturbance, specific learning
disabilities, speech or language impairments,
traumatic brain injury, or visual impairments.
Iowa determines eligibility based on a
documented educationally relevant need
rather than a specific disability category.
• Covers students with educational disabilities
that require specialized instruction and/or
related services.
• Not all students with disabilities are eligible
for services.
• Have a physical or mental
impairment that substantially
limits one or more major life
activities
• Have a record of such an
impairment
• Are regarded as having such an
impairment
(Major life activities include, but
are not limited to: walking,
seeing, hearing, speaking,
breathing, learning, working,
caring for oneself, sleeping,
concentrating, and performing
manual tasks.)
Requirements
in Law
Provide a free appropriate public education in
the least restrictive environment.
Requires any agency, school or
institution receiving federal
financial assistance to provide
persons with disabilities, to the
greatest extent possible, an
opportunity to be fully integrated
into the mainstream.
Who is
Covers students with educational disabilities
Protects all persons with a
Covered
that require special education services birth-21
or until graduation.
disability from discrimination in
educational settings based on
disability
Services
Provided
Offers educational services that are remedial in
addition to services available to all mainstream
students.
Eliminates barriers that would
prevent a student from full
participation in school
Addressing barriers
Barriers may exist when providing concussion education to students and families. Instructions
provided during a primary care or emergency visit may not be retained due to the associated
stress of the injury. Verbal instructions may be forgotten and printed instructions may not be
fully understood. Members of the school physical team, such as the school nurse or licensed
athletic trainer, can play an important role in providing basic information about concussion and
in helping to dispel some of the myths regarding concussion recovery. Information given to the
family should be written below an eighth-grade level and explained in the family’s or student’s
preferred language. Information may include post-concussion signs and symptoms, red-flag
signs and symptoms that require immediate medical care, and when to consider a referral to
other specialists for additional services.
The role of the school nurse and/or licensed athletic trainer
Students who experience a concussion may need guidance and support throughout the process
of managing the school day and the process of returning to physical activity. As part of the
concussion management team, the school nurse and the licensed athletic trainer collect
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valuable assessment information that assists the student in monitoring their own concussion
symptoms and for reporting that information to the team.
The school nurse is the professional practitioner who is responsible for overseeing and
coordinating health services, health policies, and health programs in the school community. The
school nurse provides students with health services to minimize absenteeism and promote
equal access to education. Students who have experienced a concussion may require nursing
and health services at school to access academics or school-sanctioned activities. Mandatory
education attendance laws require that students with mental or physical health needs must
have access to health services at school pursuant to Iowa Code 299. School nurse services,
designed and implemented to meet the student’s health needs, are documented in an
individual health plan (IHP). The IHP is written by the school nurse and utilizes the nursing
process as required in Iowa’s Nurse Practice Act. The components of an IHP at a minimum
contain nursing assessment data, nursing diagnosis, interventions, planning, student-centered
outcomes, and evaluation results. School nurses evaluate the school environment for barriers
that a student may experience following a concussion. School nurses collect valuable
information regarding the student’s progress during recovery and report worsening symptoms
to the concussion management team. This information becomes especially valuable when
determining the appropriate pace for “return-to-learn” and the need for additional academic
adjustments.
The licensed athletic trainer provides students with physical reconditioning, which is carried out
under the oral or written orders of a health care provider, with the permission of the student’s
parents. The licensed athletic trainer works directly with school administration or the athletic
director to establish a service plan that is under the direction of a physician. The plan should
contain the student’s name and any other identifying information, referral source, date of
service, initial assessment, results, program plan (with estimated length), program methods,
outcomes, revisions, date of discontinuation, and summary. The licensed athletic trainer
communicates the assessment results, program plans, and recovery progress with other
members of the concussion management team.
The school nurse and the licensed athletic training each provide critical support and expertise
as a part of the school physical team. It is crucial to establish a strong working relationship
between all individuals supporting the student to ensure timely and consistent communication
regarding the student’s health and progress during recovery from concussion.
8. Developing a Concussion Management Protocol
Concussion Guidelines for Iowa Schools; the REAP concussion management manual; CDC’s
“HEADS UP” materials, and the Consensus statement on concussion in sport - the 5
th
international conference on concussion in sport held in Berlin, October 2016 should be
incorporated into a concussion protocol for your school. Given that each school in Iowa is
unique, the processes and forms utilized may vary depending on the specific needs of the
school.
27 | I o w a C o n c u s s i o n G u i d e l i n e s 2017
Getting started
A good first step is to form a workgroup that will be responsible for developing a concussion
management protocol for your school. Include individuals from a variety of disciplines within
the school and community, such as those from the multi-disciplinary team outlined in Table 10,
to ensure that a well-rounded group of knowledgeable individuals participates in, or provides
input to, the workgroup.
Prior to drafting a concussion protocol, the workgroup should determine what are the current
policies or optimal practices being used that could potentially be incorporated into this process.
For example, the following questions may be helpful when developing a concussion
management protocol:
What is the practice for notifying a parent/guardian when an injury occurs during the
school day or during school activities?
What is the process parents use to report an injury or illness to the school?
How is information about a concussion communicated between the extracurricular and
the academic settings?
How are medical, cognitive, or activity restrictions and releases documented and
communicated?
What is the process for documenting medical needs, making temporary academic
adjustments, and communicating student-specific needs to staff?
How is it documented and communicated when a student is symptom-free, no longer
requires academic adjustments, or is medically cleared to return-to-play?
How are concussions currently being managed in compliance with Iowa Code 280.13C?
How are concussions currently being managed, for all students regardless of age?
When applicable, who in addition to the school nurse should be responsible for
communicating with medical providers?
The workgroup should also prepare for their initial meeting by reviewing Concussion
Management Guidelines for Iowa Schools, the REAP concussion management manual adapted
for Iowa, “HEADS UP” materials from the CDC, and other current literature regarding
concussion management best practices.
Links to the documents mentioned above are available in the resources list in Appendix
A.
Components of a good concussion management protocol
When creating a concussion management protocol for your school, it is important that the
protocol incorporates the following components:
Describes your school’s commitment to safety and concussion prevention.
Briefly describes what constitutes a concussion, including typical signs and symptoms.
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 28
Describes the method and frequency for providing education and training regarding
concussions and concussion management, including identification of target audiences.
Explains the role of the concussion management team and the point of contact for
reporting suspected concussions.
Supports all students, including both athletes and non-athletes.
Outlines the process for concussion documentation and how various information will be
communicated to all team members.
Outlines a plan for supporting students returning-to-learn.
Provides a process for safely returning students to physical activity following a
concussion.
Indicates how often the protocol will be reviewed (at least every three years) to ensure
new knowledge about concussion and concussion management is incorporated into the
protocol and is consistent with Iowa law and national best practices.
Concussion management process
Step 1: Concussion management team is established and concussion education is provided.
Set an expectation regarding student safety and share information on concussion
prevention.
Every year, share general information about concussions with students, families,
coaches, teachers, and other adults who may have a responsibility to report an injury.
Topics should include how to identify a concussion (signs and symptoms), the
importance of removing the student from activity, and the process for reporting injuries.
Identify who will serve as your school’s concussion management team leader(s) to act as
the central point of communication and coordinates the concussion management team
process. This person should be someone who is regularly available within the school.
Determine a core set of leaders within your school who should participate on every
concussion management team. It is recommended to have consistent person identified
as a “School Academic Team Leader” and a “School Physical Team Leader.”
Provide the concussion management team members with concussion training, including
the role/responsibility of each team member and the protocol for “return-to-learn” and
“return to activity.”
Communicate with teachers and staff about the role of the concussion management
team, the need for their potential participation as a team member, and their role in
providing the team with information during a student’s recovery from concussion.
At the beginning of each sport season, meet with coaches and licensed athletic trainers
to provide concussion education on the signs/symptoms of concussion, risks, concussion
management and your school’s protocol.
29 | I o w a C o n c u s s i o n G u i d e l i n e s 2017
At the beginning of each school year, meet with physical education teachers and recess
supervisors to provide concussion education on the signs/symptoms of concussion,
reducing risks, concussion management, and your school’s protocol.
Display concussion information in publicly available areas within the school building as
well as in newsletters and online.
Provide education to teachers and staff about concussion symptoms, how concussion
may affect academic learning and performance, and possible adjustments a student
might need when recovering from concussion. Information about the school’s
concussion protocol, including the role of the concussion management team should also
be shared.
Step 2: Suspected concussion occurs and student is removed from activity
If an injury occurs during school or at a school event, remove the student immediately
from activity and notify the family. Information regarding the injury is gathered,
documented, and shared with the parent/guardian. Concussion information, including
the school’s concussion management protocol, is provided to the family.
A responsible adult should remain with the student and continue to monitor for
deterioration during the initial few hours after injury. The student should not be allowed
to drive.
If the injury occurs outside of school, the family should report the injury to the school.
Remove the student from all physical activities such as PE, recess, and athletics. Student
may also need to be removed from activities such as band, choir, and music.
For more information on best practice recommendations for removal from play, see
section 5: Return to Activity & Play.
Step 3: Communication between the family and concussion management team
When the student returns to school, the concussion management team leader gathers
information from the student and family about how the concussion symptoms are
affecting the student. Information about any medical, cognitive, and physical
restrictions that are in place should also be collected. This includes what restrictions the
family has put in place at home.
The REAP manual (or online link to the manual) is provided to the family if the student is
returning to school while still experiencing concussion symptoms.
Table 2 outlines the four components of the concussion management team, including
the discipline or title of various individuals who should be included as team members.
This list is not comprehensive and, to best support the student, the school needs to
determine whether there are additional individuals who need to be notified of the
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 30
concussion. While forming the team, consider what will be the optimal method for
communicating with the various team members: verbal, written, or electronic.
The concussion management team leader coordinates the communication and
documentation of information regarding the injury, how the concussion symptoms are
impacting the student, and any follow-up medical instructions.
It is important to note that not all students will be under medical care for their
concussion. In these instances, the school concussion protocol and recommendations
from the REAP concussion management manual still apply.
A link to the REAP manual can be found in the resources list in Appendix A.
Step 4: Collect information
The concussion management team leader will act as the point person for gathering,
documenting, and sharing information regarding the student’s concussion recovery,
including classroom adjustments needed and symptoms reported or observed.
Determine the frequency with which information is collected, documented, and
communicated (recommendations are included in section 4: Implications for Learning –
Acute Recovery).
Staff should be required to submit feedback, even if no symptoms are observed and it is
perceived that the student is progressing well.
As a school team, review current methods for documenting other health
concerns/injuries and academic adjustments. If the school has the ability to document
information electronically, this may help with tracking and trending the educational
impact of concussions.
At a minimum, it is recommended that schools document when the injury occurred,
when the student is “symptom free,” and when the student obtained medical clearance.
Student history of concussion should be gathered to track potential progressive impact
of repetitive head injuries. This may include information such as how many concussions
the student has experienced, the number of school absences due to each concussion,
and length of recovery from each concussion.
Step 5: Share information
Determine who should have access to routine updates regarding the student’s progress.
Regularly share information collected about the student’s symptoms and academic
performance during the recovery phase with the concussion team as well as others who
may need this information to better support the student.
31 | I o w a C o n c u s s i o n G u i d e l i n e s 2017
If the student is receiving medical care, the family should be encouraged to share
information collected at school with the health care provider, or proper releases should
be obtained to allow the school to communicate with the health care provider directly.
Additional information about coordinating communication across settings is available in
section 7: Providing Collaborative Care after a Concussion.
Step 6: Return-to-learn & assess academic needs
Repeat Steps 3-5 until the student is symptom free. The concussion management team
should continue to monitor the student, provide appropriate adjustments, and assess
progress.
In the event a student is in a transition period (such as between sport seasons,
semesters, or academic years), information regarding the injury needs to be
communicated to the receiving authority and new concussion management team
members may be needed.
See section 3: Implications for Learning – Acute Recovery for information on academic
adjustments and the process for evaluating the student’s tolerance of increased
cognitive demands.
Step 7: Team determines student is symptom free
As the student recovers, their symptoms and need for academic adjustments may also
decrease or change. Students should not be released to full physical activity until they
have returned to school fully and are meeting pre-injury cognitive demands.
Using the information collected during the recovery phase (steps 3-5), the team will
determine whether the student is ready to move on to Step 8. This information should
be clearly documented that the student is no longer symptomatic, no longer requires
academic adjustment for the concussion, is no longer using medication to manage
concussion symptoms (including over the counter medication), and has returned to
academic baseline.
Information supporting that the student is “symptom free” within the school setting
should be provided to the parent/guardian and healthcare provider. The health care
provider should utilize this information along with their own clinical assessment and
expertise to determine where the student is in the recovery process and whether
additional actions are recommended.
Step 8: Graduated return-to-play
Students who continue to require academic adjustments related to concussion
symptoms should not be returned to play.
Iowa Code 280.13C should be referenced for Iowa law requirements.
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 32
After successful completion of the graduated return-to-play protocol, the health care
provider can give final clearance. If no health care provider is involved, the
parent/guardian can give written permission for return to activity/play. Student athletes
covered by Iowa’s concussion law are required to have medical clearance from a
healthcare provider prior to returning to their sport.
The school physical team should continue to communicate with the family and school
academic team by sharing information about the student’s recovery process while
progressing through the graduated return-to-learn steps because increased physical
activity may cause concussion symptoms to re-develop.
See section 5: Return to Activity & Play for recommended best practices.
33 | I o w a C o n c u s s i o n G u i d e l i n e s 2017
Acknowledgements
Concussion Management Guidelines for Iowa Schools was developed in 2017 through a
collaborative effort of the Iowa Department of Education and Iowa Department of Public
Health. A special thank you to Director Ryan Wise (Education) and Director Gerd Clabaugh
(Public Health) for recognizing concussion as a public health concern affecting student
achievement and safety. Thank you to the members of the Iowa Concussion Community of
Practice for their generous contributions of time and expertise.
This document is available online, without charge, at the Iowa Department of
Education https://www.educateiowa.gov/student-health-conditions
Iowa Concussion Community of Practice team members
NAME
TITLE
ORGANIZATION
Melissa Walker, RN
School Nurse Consultant
Iowa Dept. of Education
Maggie Ferguson, MS, CRC, CBIS
Brain Injury and Disability Program
Manager
Iowa Dept. of Public Health
Rachel Anderson, MSN, RN
Service Task Force Chair
Advisory Council on Brain Injuries
Alan Beste
Executive Director
Iowa High School Athletic Association
Paula Connolly
Family to Family Iowa Project
Coordinator
ASK Family Resources
Valerie Cool, PhD
Licensed Psychologist
University of Iowa, Stead Family
Children’s Hospital
Marci Cordaro, MSN, RN
Health Services Supervisor
Des Moines Public Schools
Leslie Duinink, MS, LAT
Associate Professor of Exercise Science
Central College
Eric Enderton
Emergency Medical Services for
Children Coordinator
Iowa Dept. of Public Health
Jill Kienzle, MPA, LAT, ATC
Liaison to IAHSAA
Iowa Athletic Trainers’ Society
Fred E. Kinne
Consultant for Equity;
Section 504 State Coordinator
Iowa Dept. of Education
Geoffrey Lauer, MA
Executive Director
Brain Injury Alliance of Iowa
Scott Lindgren, PhD
Professor, Stead Family Dept of
Pediatrics
University of Iowa, Carver College of
Medicine
Marianka Pille, MD, FAAP
Pediatrician
American Academy of Pediatrics
MaryAnn Strawhacker, MPH, RN, SEN
Special Education Nurse Consultant
Heartland AEA 11
Carrie VanQuathem, MS, PT, CBIS-T
Director of Pediatric Rehabilitation
ChildServe
This project was supported, in part by grant number 90TBSG0018, from the U.S. Administration for Community
Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under
government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions
do not, therefore, necessarily represent official Administration for Community of Living policy.
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 34
Appendix A: Resources
PRINTABLE MATERIAL
IHSAA and IGHSAU Concussion Management Protocol
https://www.iahsaa.org/Sports_Medicine_Wellness/Concussions/Concussion_RTP_Protocol_05
2212.pdf
REAP Concussion Management manual
http://biaia.org/ICC/reap-full-publication.pdf
Brain Injury Quick Guide: Information and Resources for Teachers & School Staff
https://idph.iowa.gov/Portals/1/Files/ACBI/Brain%20Injury%20Quick%20Guide%20For%20Scho
ols%20july.pdf
CDC Heads Up to Schools
https://www.cdc.gov/headsup/schools/
Get Schooled on Concussion
http://www.getschooledonconcussions.com/
Concussion Recognition Tool 5
http://bjsm.bmj.com/content/51/11/872
Sport Concussion Assessment Tool (SCAT3) – 3
rd
Edition
http://bjsm.bmj.com/content/bjsports/47/5/259.full.pdf
Sport Concussion Assessment Tool (SCAT5) – 5
th
Edition
http://bjsm.bmj.com/content/bjsports/early/2017/04/28/bjsports-2017-097506SCAT5.full.pdf
Child SCAT5 Sports Concussion Assessment Tool for Children ages 5 to 12 (for use by medical
professionals only)
http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-
097492childscat5.full.pdf
WEBSITES
Iowa Department of Education, Student Health Conditions
https://www.educateiowa.gov/student-health-conditions
Iowa Department of Public Health, Brain Injury Services Program
http://idph.iowa.gov/brain-injuries
Iowa High School Athletic Association, concussion page
http://www.iahsaa.org/Sports_Medicine_Wellness/Concussions/concussions.html
Brain Injury Alliance of Iowa (BIA-IA), Resource Facilitation Program
35 |
I o w a C o n c u s s i o n G u i d e l i n e s 2017
1-855-444-6443 or [email protected] for more information and support
http://biaia.org/
www.IowaConcussion.org
BIA-IA brain injury resource virtual tote bag http://biaia.org/support.htm
ASK Resource Center
http://askresource.org/resources/
BrainLine Kids
http://www.brainline.org/landing_pages/features/blkids.html
Brain STEPS: Strategies Teaching Educators, Parents, & Students
http://www.brainsteps.net
CDC’s Heads Up
https://www.cdc.gov/headsup/index.html
Center on Brain Injury Research and Training (CBIRT)
http://cbirt.org
Project LEARNet from BIANYS
http://www.projectlearnet.org/
VIDEOS
Brain Injury Alliance of Iowa – REAP Concussion Management Protocol
https://www.youtube.com/playlist?list=PLHHCQ1nyoAofPHvzMRLTnG-fBRs0t_Zve
Helping Students with Brain Injuries online video series (module 4: Concussion)
www.training-source.org
Brain 101
https://www.youtube.com/watch?v=_5hlm3FRFYU
CDC Heads UP concussion videos
https://www.cdc.gov/headsup/resources/videos.html
CDC Heads Up to Youth Sports: Online Training
https://www.cdc.gov/headsup/youthsports/training/index.html
National Federation of State High School Associations’ Concussion in Sports video (required for
coaches)
https://nfhslearn.com/courses/61064/concussion-in-sports
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 36
APPS (available for free)
HEADS UP Concussion and Helmet Safety app
Apple Store: https://itunes.apple.com/us/app/cdc-heads-up-concussion-
helmet/id999504040?mt=8
Google Play: https://play.google.com/store/apps/details?id=gov.cdc.headsup&hl=en
HEADS UP Rocket Blades (available in Apple App Store. Android version coming soon)
https://itunes.apple.com/us/app/cdc-heads-up-rocket-blades-the-brain-safety-
game/id1212332624
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Appendix B: Symptom checklist
Credit: HCA HealthONE, 2016
Student name:
Person completing checklist (if not the student):
Date: Time:
□ baseline* □ post injury*
Symptoms Severity Rating
I feel like I’m going to faint
0
1
2
3
4
5
6
I’m having trouble balancing
0
1
2
3
4
5
6
I feel dizzy
0
1
2
3
4
5
6
It feels like the room is spinning
0
1
2
3
4
5
6
Things look blurry
0
1
2
3
4
5
6
I see double
0
1
2
3
4
5
6
I have headaches
0
1
2
3
4
5
6
I feel sick to my stomach (nauseated)
0
1
2
3
4
5
6
Noise/sound bothers my eyes
0
1
2
3
4
5
6
The light bothers my eyes
0
1
2
3
4
5
6
I have pressure in my head I feel numbness and tingling
0
1
2
3
4
5
6
I feel numbness and tingling
0
1
2
3
4
5
6
I have neck pain
0
1
2
3
4
5
6
I have trouble falling asleep
0
1
2
3
4
5
6
I feel like sleeping too much
0
1
2
3
4
5
6
I feel like I am not getting enough sleep
0
1
2
3
4
5
6
I have low energy (fatigue)
0
1
2
3
4
5
6
I feel tired a lot (drowsiness)
0
1
2
3
4
5
6
I have trouble paying attention
0
1
2
3
4
5
6
I am easily distracted
0
1
2
3
4
5
6
I have trouble concentrating
0
1
2
3
4
5
6
I have trouble remembering things
0
1
2
3
4
5
6
I have trouble following directions
0
1
2
3
4
5
6
I feel like I am moving at a slower speed
0
1
2
3
4
5
6
I don’t feel “right”
0
1
2
3
4
5
6
I feel confused
0
1
2
3
4
5
6
I have trouble learning new things
0
1
2
3
4
5
6
I feel like my thinking is “foggy”
0
1
2
3
4
5
6
I feel sad
0
1
2
3
4
5
6
I feel nervous
0
1
2
3
4
5
6
I feel irritable or grouchy
0
1
2
3
4
5
6
I feel more emotional
0
1
2
3
4
5
6
Other:
0
1
2
3
4
5
6
*For baseline, student should rate symptoms based on how he/she typically feels.
For post-injury, student should rate symptoms, at this point in time.
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 38
| I o w a C o n c u s s i o n G u i d e l i n e s 2017
Appendix C: Teacher feedback form
39
Credit: HCA HealthONE, 2016
References
1. Center for Disease Control and Prevention. HEADS UP to Youth Sports.
https://www.cdc.gov/headsup/youthsports/index.html
2. Center for Disease Control and Prevention, National Center for Injury Prevention and Control.
Concussion at play: Opportunities to reshape the culture around concussion.
https://www.cdc.gov/headsup/pdfs/resources/concussion_at_play_playbook-a.pdf
3. Children’s Safety Network. (May 2013). Strategies for Preventing Sport-Relate Concussions and
Subsequent Injury.
4. Colorado Department of Education Concussion Management Guidelines. (2014).
https://www.cde.state.co.us/healthandwellness/concussionguidelines7-29-2014-0
5. Gioia, G. A., Glang, A. E., Hooper, S. R., & Brown, B. E. (2016). Building statewide infrastructure for
the academic support of students with mild traumatic brain injury. Journal of Head Trauma
Rehabilitation.
6. Halstead, M. E., McAvoy, K., Devore, C. D., et al. (2013). Returning to learning following a
concussion. Pediatrics.
7. Iowa High School Athletic Association Iowa Girls High School Athletic Union. (2012). Concussion
Management Protocol.
http://www.iahsaa.org/Sports_Medicine_Wellness/Concussions/Concussion_Management_Protoco
l_WITH_RTP_Final_060713.pdf
8. McAvoy, K. (2016). REAP the benefits of good concussion management, third edition (Iowa Version).
9. McAvoy, K. (2012). Returning to learning: Going back to school following a concussion.
Communique.
10. McCrory P, Meeuwisse W, Dvorak J, et al. (2017). Consensus statement on concussion in sport – the
5
th
international conference on concussion in sport held in Berlin, October 2016. British Journal of
Sports Medicine.
11. Nationwide Children’s. An educator’s guide to concussion in the classroom, 2
nd
edition.
12. Nationwide Children’s. A school administrator’s guide to academic concussion management.
13. Sady, M. D., Vaughan, C. G., & Gioia, G. A., (2011). School and the concussed youth:
Recommendations for concussion education and management. Physical Medicine Rehabilitation
Clinical North America.
I o w a C o n c u s s i o n G u i d e l i n e s 2017| 40