1. Prince William County Public Schools High School Concussion Education
For Grade 9 and New High School Students
Part 1 Introduction
Welcome to the Prince William County Public School’s concussion education training for the following high school audiences:
Rising ninth grade students and parents
Students in grades 10 through 12 and their parents who have not taken the high school Face-to-Face training.
(3) Students and parents new to Prince William County Public Schools.
This training will take you approximately 40 to 50 minutes. Parents and students must be together when taking this training.  
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2. Presentation Objectives
This presentation will provide you:
Definition of concussion and Second Impact Syndrome;
Identify possible signs and symptoms of a concussion or Traumatic Brain Injury (TBI);
Understand the process for reporting a concussion
Learn Prince William County Public Schools concussion management process;
Understand who to contact for proper medical treatment and referral guidelines
Understand the protocol for Return-to-Learn [Return-to-School]and Return-to-Play
[Read Slide Bullets]
After this presentation parents and students will:
Definition of concussion and Second Impact Syndrome
Identify possible signs and symptoms of a concussion or Traumatic Brain Injury (TBI)
Understand the process for reporting a concussion
Learn Prince William County Public Schools concussion management process
Understand who to acquire proper medical treatment from and referral guidelines
Understand the protocol for Return-to-Learn and Return-to-Play
Note: The terms Return-to-Learn and Return-to-School are synonymous. Prince William County Public School concussion protocol will use the term “Return-to-Learn”.
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3. Virginia State Law
On an annual basis, each school district shall provide student athletes with information on concussions and each student athlete and the student athlete's parent/guardian shall sign a statement acknowledging receipt of the information. The athlete must obtain written clearance to return to play from the health care provider.
Virginia State Law Requires
On an annual basis, each school district shall provide student athletes with information on concussions and each student athlete and the student athlete's parent/guardian shall sign a statement acknowledging receipt of the information.
The athlete must obtain written clearance to return to play from the health care provider.
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4. Virginia State Law
Policies and regulations implemented by Prince William County Public Schools for handling student-athlete concussions, include the state mandated protocol and care for athletes suspected of sustaining a concussion or head injury. This includes the removal from play until evaluated by a licensed health care provider.
Policies and regulations implemented by Prince William County Public Schools for handling student-athlete concussions, include the state mandated protocol and care for athletes suspected of sustaining a concussion or head injury. This includes the removal from play until evaluated by a licensed health care provider.
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5. Prince William County Regulation
All staff, coaches, school health nurses, certified athletic trainers, volunteer coaches, participating students, and parents/guardians of participating students will complete concussion training annually.
The training will include the Return-To-Play and Return-To-Learn protocols that will be implemented when a concussion injury occurs.
End of Part 1
Prince William County requires that all staff, coaches, school health nurses, certified athletic trainers, health and physical education staff, volunteer coaches, participating students, and parents and/or guardians of participating students, complete concussion training every year.
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6. Concussion Defined
A concussion is a brain injury that results in the rapid onset of short-lived impairment of neurological function that resolve.  
Direct force- a blow to the head, face or neck 
Indirect force- elsewhere on the body with an impulsive forces that is transmitted to the head
A concussion is a brain injury that results in the rapid onset of short lived impairment of neurological function that resolve. This injury is caused either by a blow to the head, face or neck, or elsewhere on the body with an impulsive forces that is transmitted to the head, (i.e., a helmet to the head, being knocked to the ground). A concussion can occur with or without a loss of consciousness, and proper management is essential to the immediate safety and long-term future of the injured individual. A concussion can be difficult to diagnose, and failing to recognize the signs and symptoms in a timely fashion can have dire consequences
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7. Effects of Concussive Forces on the Brain
This invisible injury disrupts the way the brain normally works by affecting mental stamina, as the brain must work longer and harder even to complete simple tasks.
This invisible injury disrupts the way the brain normally works by affecting mental stamina, as the brain must work longer and harder even to complete simple tasks. Concussions also affect reaction time, short-term memory, working memory and cognitive processing speed.
Think of you brain like a cell phone, when you get a concussion your battery life goes down. It's harder to charge it back up to 100%, since a lot of the power goes to healing your brain. Trying to do normal activites causes the battery to drain more quickly. The student feels run down and post concussion symptoms get worse. Prioritize activities that are most important and plan to do those activities when the battery is at full charge. Let the student take breaks to recharge their battery. 

8. Effects of Concussive Forces on the Brain
A concussion is a functional injury, not a structural injury.
Typically, the “software” of the brain is affected, chemical changes.
Not the “hardware” or a physical injury.
When a concussion occurs often there is no visible damage such as bleeding or a fracture. The damage is not to the skull or brain itself, the “HARDWARE,” but rather to the “SOFTWARE” which causes a breakdown in the function of the brain.
For example, if you dropped your phone you may have visible damage such as cracks on the screen or dents, where as with a concussion it is more like the damage a virus causes inside the phone.
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9. Signs or Symptoms Observed by Coaches, Staff and Teammates
Slow reaction time
Loss of consciousness
Balance problems
Headache
Behavioral changes
Dizziness
Dazed or confused
Memory loss 
Confusion
Sleep/wake disturbances
Signs that might be observed by students or staff might include; personality changes, confusion about assignments, unsure about game, score or opponent, inability to recall events prior to or following the injury.
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10. Signs or Symptoms at Home
Behavioral changes
Difficulty completing tasks
Reduced play/ activity
Changes in sleep patterns
Peronality changes
Fatigue
Irritability
Following a head injury everyday functions can be effected. They may have difficulty completing tasks at home or in school, become irritable easily and may experience periods of excessive sadness.
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11. Signs or Symptoms in the Classroom
Decreased attention span
May not be able to finish homework assignments
Difficulty concentrating
May not be able to take tests in school
Slowed reaction time
May be slow to answer questions
Driving can be impaired
Visual Sensitivities
Student may strggle with screen time (smartboard, computer)
A+ student may become C- student
Effects of a concussion may impact the student in the classroom. In addition, it also affects tasks such as driving. An athlete who sustains a concussion should NEVER drive themselves home. Athletes may exhibit a decreased attention span, find it difficult to concentrate on simple tasks and may also be slow to respond to questions.
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12. Referral Guidelines
An athlete will be immediately referred to an Emergency Department via ambulance in the event of…
Witnessed or reported loss of consciousness 
Decreasing level of consciousness
Difficulty breathing
Suspected spine injuries or skull fractures
Following an emergency department visit, all athletes must follow up with a primary care physician or specialist!
Athlete’s parents will be given a copy of the Acute Concussion Evaluation to take to take their physician or ER for a follow up evaluation.
An athlete will immediately be referred to an Emergency Department via ambulance in the event of…
• Witnessed or reported loss of consciousness
• Decreasing level of consciousness
• Difficulty breathing
• Suspected spine injuries or skull fractures
Following an emergency department visit, all athletes must follow up with a primary care physician.
After sustaining a concussion, the athlete’s parents will be given a copy of the Acute Concussion Evaluation or Ace form to take to their physician or to the emergency room for a follow-up evaluation.
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13. How long does it take for symptoms to resolve?
Just like Snowflakes… No Two Concussions Are Alike
No one knows how long it will take for symptoms to resolve!
The question is how long does it take for brain function to equalize? Patience is important since every athlete responds differently to a head injury. We need to wait and let the brain recover, to prevent further damage or prolonged symptoms.
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14. Importance of Managing Concussion Risks
Timely evaluation by an appropriate medical provider, trained in concussion evaluation and management.
Return to play for 3 minutes after a concussion increases your risk for prolonged recovery
Clinical evaluation, vestibular testing and ImPACT are tools used to diagnose a concussion.
NO imagining techniques used will detect concussions.
Concussion symptoms may last as short as several minutes and can last as long as several days, weeks, months, or even longer in some cases. The traditional thought that, “the younger you are the quicker you heal” does not apply to brain injuries and in fact the younger the athlete the longer the recovery process. If not managed properly an athlete suffering from a concussion is more likely to be re-injured and poses an increased risk of permanent medical disqualification from sport.
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15. What’s the worst thing that could happen???
Symptoms in a student athlete may not manifest until 72 hours later. For example an athlete hit in a Friday night's game may not experience symptoms until Monday.
In the picture the athlete is kicked in the face and has a nosebleed. He does not have any concussion symptoms at the time of the injury. The injury happened on a Friday night. Over the course of the weekend, he develops a headache and other concussion symptoms.
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16. Second Impact Syndrome
Second Impact Syndrome occurs when an athlete, who has already sustained a head injury, sustains a secondary head injury before symptoms have fully resolved.
Second Impact Syndrome occurs when an athlete, who has already sustained a head injury, sustains a secondary head injury before symptoms have fully resolved.
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17. Second Impact Syndrome
Can result in loss of brain function, decreased blood supply, and increased intracranial pressure.
Only occurs in persons under the age of 23
50% of occurrences are fatal
100% result in some form of physiological, cognitive, and/or emotional disability
Second impact is only reported in persons under the age of 23 and most commonly found in adolescents. 50 percent of occurrences are fatal and 100 percent result in some form of physiological, cognitive, and/or emotional disability.
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18. Concussion Recovery: Everyone has a responsibility to:
Know Concussion Signs and Symptoms
Understand importance of communication
Work collaboratively to implement Return-To-Learn progression when required
Understand the protocol for Return-To-Play
During the concussion recovery everyone has a responsibility of being aware of Communication and the protocol for Return to Learn and Return to Play.
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19. Coaches Responsibility: Four Step Action Plan
Step 1:  Remove the athlete from play. DO NOT try to judge the severity of the injury yourself..
Step 2: Ensure that the athlete is evaluated by a health care professional experienced in evaluating concussions.
Step 3: Inform the athlete’s parents or guardians about the possible concussion.
Step 4:  Keep the athlete out of play until they receive clearance from the health care professional. 
Coaches will be responsible for removing the athlete from play when a head injury has occurred and a concussion is suspected. They will ensure that the athlete is evaluated by a health care professional experienced in evaluating concussions and inform the athlete’s parents or guardians about the possible concussion in the absence of the athletic trainer. Coaches will keep the athlete out of play until they have met all requirements of the return to play progression.
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20. Parents Responsibilities
Support the decision to remove from further play in high school and recreational sport leagues
Contact ATC, coach, and/or administration if your child reports symptoms to you following practice/game
Encourage rest both cognitive and physical
Understand the Return-To-Play and Return-To-Learn protocols
Parents play a crucial role in the their athlete’s recovery. An athlete that is suspected of having a concussion should not be permitted to participate in activities both in and outside of the school setting. Not all injuries are reported to Athletic Trainer or coach at time of injury. If your child reports signs and symptoms of a concussion, please follow up with Athletic Trainer and/or coach so the proper post-injury process can begin. Encourage rest and remember: “WHEN IN DOUBT, SIT THEM OUT!!”
WHEN IN DOUBT, SIT THEM OUT!
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21. Student-Athlete Responsibilities
Report symptoms to coaches and athletic trainers
50% to 70% of concussions go unreported
Advocating for themselves in the classroom
Communicate consistantly with all memers of the concussion management team and parents.
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22. Role of a Licensed Athletic Trainer (AT)
As a licensed health care provider through certification by the Virginia Board of Education, Virginia Board of Medicine and Virginia Concussion Law, the AT is able to provide:
Evaluation  of the student-athletes for potential concussion after head injuries;
Collaborate with a physician to determine concussion management;
Direction for  the use of the PWCS concussion policy and protocol; Return-To-Learn & Return-To-Play
Read Slide
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23. Responsibilities of the PWCS Athletic Trainer
Monitor Return-To-Learn & Monitor Return-To-Play
When symptoms are apparent, recommendations are provided to begin recovery;
Assess student injuries to determine next steps using approved sideline assessment tools
Provide ImPACT testing to all athletes prior to the season and after injury
Read slide
Athletic Trainers perform an essential role in:
(1) Maintaining communication with parents, coaches and academic team members to facilitate the recovery process.
(2) Providing follow up care
(3) Implementing return to play and return to learn progression.
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24. Concussion Testing & Monitoring Tools
ImPACT testing
Annual baseline testing prior to sport season for all athletes per county reg 759-1
Post-concussion testing and retesting completed at appropriate intervals
Sideline Assessment (ie SACVNI, SCAT5, etc)
Exam consists of short-term memory, delayed recall, orientation, exertional maneuvers, concentration, and neurological function
ACE (Acute Concussion Evaluation) complete after assessment for communication between health care providers. 
SAC VNI is a sideline assessment tool designed to assist athletic trainers in evaluating concussion injuries. The exam consists of short term memory, delayed recall, orientation, exertional maneuvers, as well as concentration and neurological function.
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25. Who is an appropriate medical professional?
APPROVED
State Licensed Athletic Trainer
Primary Care Physician
Neuropsychologist
Physician’s Assistant
Nurse Practitioner
Doctor of Osteopath
NON APPROVED
ER Doctor (no follow-up care)
Urgent Care Physician
Chiropractor
Physical Therapists
Athletes may be released to begin return to play progression but the following health care providers, primary care physician, neuropsychologist, physician’s assistant, nurse practitioner, doctor of osteopath and a state licensed athletic trainer.
Non approved providers are Emergency Room Doctor’s as they are not able to provide adequate follow-up care, urgent care physicians, chiropractors and physical therapists.
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26. Communication as a Team
Development of Concussion Management Teams (CMTs) and a working chain of communication is imperative.
This initiative will allow for smooth transitioning of students suffering from concussion back to the classrooms.
Concussion teams within the school share common roles and responsibilities to assist other team members and the concussed student. 
It is very important to have lines of communication available to assist the student’s recovery from a concussion. To meet this need, PWCS has identified the need for school based Concussion Management Teams as a way to monitor smooth transitioning of students suffering from concussion back to the classrooms.
These teams should be in place as support for the student and the parents in a process that has many uncertainties. Working together to support recovery and academic progress will help to reduce the potential anxiety that a student may experience.
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27. Communication is a MUST!
Concussed Student
Parents
Primary Care Physician
Nurse
School Administrator
Counselor
Academic Team
Athletic Staff
Student needs to hear from educators, coaches and parents that they understand. 
Reassurance that he or she will be successful in making up missed school days and homework. 
The student should hear a consistent message from everyone involved, from parents or guardians to health care providers to teachers. 
This sympathy, understanding and consistency from all parties involved will help to decrease stress, and in turn, help with recovery.
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28. As of July 1, 2016
The State of Virginia passed legislation for Return-To-Learn protocol that provided six specific phases that provide guidance for schools and staff to follow that support student recovery from concussion. All staff shall use the protocol outlined in the Concussion Management Regulation 759 –1. Utilizing the information in this presentation to implement a RTL process will enable a student to sustain progress in school and achieve recovery.
The State of Virginia passed legislation for Return to Learn protocol that provided six specific phases that provide guidance for schools and staff to follow that support student recovery from concussion.
All staff shall use the protocol outlined in the Concussion Management Regulation 759 – 1.
Utilizing the information in this presentation to implement a RTL process will enable a student to sustain progress in school and achieve recovery.
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29. Return-To-Learn Framework
Which phase  a student starts is dependent on the severity of  the concussion?
Phase 1
No School – Cognitive and Physical Rest
Phase 2
No School Rest with Light Cognitive Mental Activity and Limited Physical Activity.
Prince William County Public Schools has implemented a Return to Learn program that enables a student to return to portions or all of their school related work with the decrease of symptoms. With collaborating information from the health care provider, teachers, administrators, and parents, the student may enter one of the phases to remain as current as possible with the academic needs of the student.
Phase 3
Half Day Attendance with Moderate Instructional Modifications
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30. Return-To-Learn Framework cont.
Phase 4
Half Day Attendance with Maximum Instructional Modifications
Phase 5
Full Day Attendance with Minimal Instructional Modifications
As long as the student is able to continue recovery and not experience an increase in symptoms, the student can move to through each phase until recovery is complete.
A key component of understanding this phase program is that a student maybe in a phase for an undetermined amount of time. It could be from one day to many days.
Every student’s ability to reach full recovery is different and will vary in the length of time it takes.
Phase 6
Full School and Extra-Curricular Involvement
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31. How Can Everyone Help?
Every concussion is different, and each student may need different assistance
Type and severity of symptoms should be used as a guide to identify the course of action to be taken.
Understand common symptom triggers
Reading
Computer use
Prolonged concentration
Triggers are variable and will differ from student to student.
In general, a full “return to school” may be completed in six phases. Teachers can help by having the awareness of the symptoms and the “triggers’ that may cause an increase in symptoms. Because the purpose of each phase is to identify what the student can do without increasing symptoms (as increasing symptoms may delay recovery) and avoiding the “triggers” that do worsen symptoms. Examples of common school-related symptom triggers are reading, note taking, computer use for classwork, and prolonged concentration. However, triggers are variable and will differ from student to student.
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32. Activities Beyond Classroom Learning May Impact Recovery
Driving or loud bus rides
Dances, pep rallies and assemblies
Classes with excessive noise, such as woodworking, auto mechanics, etc.
After school sponsored events
Band/choir
Movies in school 
Computer use in classes like keyboarding, drafting, animation and film
Cafeteria, dining halls and busy hallways
Concussion recovery means that all activates in a student’s school life may require changes to support recovery.
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33. Return to Play (RTP) In PWCS there is NO SAME DAY RETURN TO PLAY!!
“It is not appropriate for a child or adolescent student-athlete with concussion to RTP on the same day as the injury.”
Zurich consensus statement on concussion in sport (2012)
In PWCS there is NO SAME DAY RETURN TO PLAY!!
The Zurich consensus statement from 2012 states that, “It is not appropriate for a child or adolescent student-athlete with concussion to return to play on the same day as the injury.”
In PWCS if a there is any suspicion of a concussion injury, there is NO SAME DAY RETURN TO PLAY!! !!
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34. When Does Return-To-Play Process Start?
Must have minimal symptoms at rest and with exertion to start RTP.
Symptom 
ImPACT post-injury assessment must be within normal range
Post Injury 
Clearance from a licensed health care professional trained in evaluating concussions.
Clearance
Completed the Return-to-Learn Process
RTL
An athlete must meet the following criteria prior to completing the Return-To-Play progression.
The athlete must have minimal symptoms at rest and with exertion to start stage 1 of the RTP process.
The athlete’s post-injury assessment must be within normal range
The athlete must be have clearance from a licensed health care provider trained in evaluating concussions.
The athlete has completed the six phases of the Return-to-Learn Process.
Key Point: Even though the athlete has been cleared by a physician and released to start the Return-to-Play progression in PWCS high school program, the Athletic Trainer monitors an athlete’s Return To Play progression.
Let’s take a more detailed looked at the Return to Play process in the next slide.
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35. Return-To-Play
Only when an athlete is cleared by a licensed health care professional, is the athlete released to begin the Return-To-Play progression. The Athletic Trainer will monitor the progress at the middle school and high school level.
Only when an athlete is cleared by a licensed health care professional, is the athlete released to begin the Return-To-Play progression. The Athletic Trainer will monitor the progress at the middle school and high school level.
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36. Return-To-Play Progression
Return-To-Play progression is a series of phases to assess the athlete’s readiness to return to sport. Each step should take approximately 24 hours to complete. On average it will take an athlete at least one week to proceed throughout the full rehabilitation protocol. If the athlete experiences post-concussion symptoms during any phase, the athlete will drop back to the previous level and resume progression after 24 hours. Weight training is NOT permitted until stage 4 of the progression. Progression through the stages must be done under the supervision of the Athletic Trainer.
Stage 1 can begin when symptoms have started to dissipate. Stage 6 of the RTL must be completed prior to moving past stage 2.
The next slide will show you how the Return-to-Learn and the Return-To-Play process inter relate.
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37. Return-To-Play Progression (RTP)
previous history of concussion
duration and type of symptoms 
age and sex of the athlete 
sport/activity in which the athlete participates
Student’s individual traits : learning disorders, ADHD, Mood disorders, history of migraines
Factors that may affect the rate of progression
include:
Athletes with a history of concussions typically progress slower and are treated in a more conservative manner. Lower contact or non-contact sports may have a quicker return to play that of high contact sport athletes because there is no need for the full contact practice step. Athletes participating in a high contact sport may have to be progressed more slowly, due to the level of contact of their sport which can effect the overall safety of the athlete and his/her teammates.
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38. PWCS Commitment to Recovery:
“Our main goal is to ensure that PWCS students and student-athletes who sustain concussions are properly diagnosed, given adequate time to heal, and are comprehensively supported at home and school throughout the recovery of their injury.”
Our main goal is to ensure that PWCS students and student-athletes who sustain concussions are properly diagnosed, given adequate time to heal, and are comprehensively supported at home and school throughout the recovery of their injury.”
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39. Take Home Message Be familiar with concussion signs/symptoms
Consult with an appropriate health care specialist
Each concussion will be dealt with on an individual basis.  
Academic support is key to recovery and available for all students in the form of the Return to Learn framework.
All athletes are required to complete Return-To-Play progression once they have received written clearance
Familiarity with the concussion signs/symptoms can play a valuable role in the health and well-being of student-athletes. Refer to a health care specialist whenever an athlete’s condition deteriorates or a spinal injury is suspected. Academic support is key to recovery and remember that each concussion should be dealt with on an individual basis. All athletes are required to complete the return-to-play progression, once they have written clearance.
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40. IT’S BETTER TO MISS ONE GAME THAN TO MISS THE WHOLE SEASON!
Remember Athletes!....
Don’t hide it, report it and take time to recover.
If you suspect that a teammate has sustained a concussion report it immediately to your coach and athletic trainer. It could save his/her life.
IT’S BETTER TO MISS ONE GAME THAN TO MISS THE WHOLE SEASON!
Athletes always remember, if you think you have a concussion don’t hide it, report it and take the time to recover. If you suspect that a teammate has sustained a concussion report it immediately to your coach and athletic trainer, it could save a life. IT’s BETTER TO MISS ONE GAME THAN TO MISS THE WHOLE SEASON!
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41. Where Can I Find More Information about Concussions?
PWCS website
Individual school website 
Athletic web pages for each school
Athletic training web pages 
The(NFHS) offers a FREE Concussion course.
You can find more information about concussion from:
PWCS website
Individual school website
Athletic web pages for each school
Athletic training web pages
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42. References
ImPACT Applications, Inc. | 2000 Technology Drive | Suite 150 | Pittsburgh, PA 15219
Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333, USA CDC-INFO ( ) TTY: (888) , 24 Hours/Every Day -
McCroryP, et al. Summary and Agreement Statement of the 5th International Conference on Concussion in Sport, Berlin, ERJ Sports Med. 2017;
Guskiewicz KM, et al. National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. J Athl Train. 2004;39(3):
The National Federation of State High School Associations
Sports Concussion Institute
This concludes the high school concussion presentation.
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43. Concussion 101 ©2011 Michael Evans and Mercury Films Inc.
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