The NCAA committee responsible for recommending rules and policies on student-athlete health and safety has proposed a new playing rule for every championship sport that would prohibit student-athletes who have lost consciousness from returning to play for the duration of that day.

The Committee on Competitive Safeguards and Medical Aspects of Sports, which met this week in Indianapolis, also agreed to a number of other policy-related and educational actions to improve understanding of and response to concussions in all sports.

They include a revision of the NCAA Sports Medicine Handbook guideline addressing concussions and the scheduling of a summit meeting in midyear 2010 to review NCAA policies for medical management of concussions and prevention strategies appropriate to the collegiate environment.

The proposed playing rule, subject to review by the NCAA Playing Rules Oversight Panel as early as mid-January, would mandate removing from competition a student-athlete “who exhibits signs, symptoms or behaviors consistent with a concussion.”

That student-athlete would not be permitted to resume competition until cleared by a physician or another health-care professional designated by the physician to provide clearance. If the symptom is a loss of consciousness, amnesia or persistent confusion, the athlete would not be permitted to return to play that day.

In the latter case, the rule would specify that only a physician could clear the student-athlete’s return to practice or competition.

“Symptoms of a concussion can vary widely,” said Ron Courson, director of sports medicine at Georgia and a member of the committee. “But there are some symptoms that absolutely preclude you from going back into activity, at least for that game day or practice day.

“Definitely, one is loss of consciousness, another is amnesia, and a third is persistent confusion. If a student-athlete has any of those symptoms, he or she would be removed from competition and would not return that day. And the student-athlete would have to follow up with a physician, or if there is not a physician on site, he or she would have to see one before being cleared for activity.”

Policy revision

Pending consideration of the rule change, the committee also revised its guideline in the NCAA Sport Medicine Handbook advising member institutions on responses to concussion injuries and procedures for returning student-athletes to competition or practice.

The revised statement emphasizes:

“Any athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulty with memory function should not be allowed to return to play during the same day of competition.

“It has been further demonstrated that retrograde amnesia, post-traumatic amnesia, and the duration of confusion and mental status changes are more sensitive indicators of injury severity; thus, an athlete with these symptoms should not be allowed to return to play during the same day. These athletes should not return to any participation until cleared by a physician.

“It is essential that no athlete be allowed to return to participation when any symptoms persist, either at rest or exertion.”

The committee believes the language reinforces medical policies that already are in place at many NCAA institutions, while encouraging institutions to develop protocols under the direction of a physician for responding to possible concussions.

 “I would say this is standard medical practice,” Courson said. “We want to make sure that we treat every student-athlete the same way, regardless of the sport, using the best medical practices.”

 The guideline continues to state that an institution and its medical team retain authority over deciding when an injured athlete can return to play.

“Our stance is that medical care is best conducted at the local level and medical decisions are best made at the local level, for individualized student health care,” said David Klossner, NCAA director of health and safety and staff liaison to the competitive-safeguards committee.

It also continues to recommend that a student-athlete should be cleared for participation in a step-by-step fashion, gradually building to physical exertion and risk of contact.

Courson described the protocol he follows at Georgia, as an example.

“We’ll do a concussion evaluation on the sideline to test for cognition, for memory and how well they function. We’ll assess their balance, and then we’ll do some exertional tests, which may consist of some pushups or situps or up-down squat thrusts. We want to try to move them around and get the heart rate up, change their head position rapidly, then make sure to run them on the sideline and do some sport-specific things. Then, we’re going to try to simulate some contact – for example, if it’s an offensive lineman, I may take a defensive lineman, have them line up and actually hit each other a couple of times. Through that process, if they still don’t exhibit any symptoms, then, in conjunction with your physician’s evaluation, you may make a decision to let them go back.

“You’ve got to have a very orderly evaluation process, with rest and exertion.”

Ongoing review

The committee’s actions were prompted both by its scheduled periodic review of concussion issues and by new data for fall sports obtained through the NCAA’s Injury Surveillance System. Those data indicate that although concussions remain among the most common injuries in football and soccer, the rates at which the injury occurs in those sports may have leveled off during the past five years after rising persistently since 1988.

Although reasons for the change in trend are not documented, committee members believe improved reporting of concussion injuries may have been helped push the rate higher. They hope that rules and policy actions of recent years have arrested the upward trend. Further data from winter and spring sports will be available during 2010, and the committee plans to publish the information.

Committee members reviewed the new ISS data for fall sports with Dr. Steve Marshall, an epidemiologist-statistician at North Carolina and director of epidemiology and biostatistics at the Datalys Center, which collects and compiles injury data for the NCAA. They also reviewed current policies of National Federation of State High School Associations and National Football League and discussed findings of a recent international conference on concussions conducted in Zurich, Switzerland.

The committee also consulted during its meeting with two other authorities who recommended possible courses of action. They are Dr. Julian Bailes, professor and chairman of the department of neurological surgery at West Virginia and a member of the NFL Players’ Association committee on concussions and traumatic brain injury, and Dr. Margot Putukian, head team physician at Princeton and a participant in the Zurich conference, who oversaw a significant revision of the Sports Medicine Handbook guideline on concussions in 2004.

Summit meeting and education

A proposed “Concussion in Collegiate Sports Summit” could provide more information for the committee’s use.

The meeting, at a location and date to be determined, would involve key constituencies including competitive-safeguards committee members, subject experts, medical professionals, athletics administrators, coaches, equipment manufacturers, student-athletes and media.

The summit would provide an opportunity to explore emerging trends in medical management of concussions. Topics could include differences in student-athletes’ willingness to reveal a possible concussion analyzed by sport and gender; possible limitations on head contact during practice; uses of tools such as neuropsychological and balance postural testing and biomarkers; complications arising from injury such as depression, anxiety or learning disabilities; and the potential for use of dietary supplements such as DHA and omega 3 fatty acids in injury management and prevention.

In another primary action, the committee considered various educational initiatives.

Chief among those is the production of a video by fall 2010 to educate student-athletes about the dangers of concussions and to improve awareness of the issue among coaches and game officials. The video would feature high-profile coaches and athletes as well as medical professionals and would emphasize best practices for responding to head injury.

“Many times a student-athlete with a concussion can compete at a fairly high level and withhold the symptoms,” Courson said. “We want to educate student-athletes on the seriousness of a concussion, so that they will know to come forward.

“We want to educate the sports-medicine staff about standardization of protocols. We also want to educate the coaches and officials to prepare them for situations in a game or in practice where they may be working with the sports medicine staff.”

Competitive-safeguards committee recommendations and actions

Recommended playing rules change in all sports

• “An athlete who exhibits signs, symptoms, or behaviors consistent with a concussion (such as unconsciousness, amnesia, headache, dizziness, confusion, or balance problems), either at rest or exertion, shall be immediately removed from practice or competition and shall not return to play until cleared by a physician or her/his designee.”
• “Athletes who are rendered unconscious or have amnesia or persistent confusion shall not be permitted to continue for the remainder of the day. These athletes shall not return to any participation until cleared by a physician.” 

New statements in concussion guideline of NCAA Sports Medicine Handbook

• “Any athlete exhibiting an injury that involves significant symptoms, long duration of symptoms or difficulties with memory function should not be allowed to return to play during the same day of competition.”
• “It has been further demonstrated that retrograde amnesia, post-traumatic amnesia, and the duration of confusion and mental status changes are more sensitive indicators of injury severity, thus an athlete with these symptoms should not be allowed to return to play during the same day. These athletes should not return to any participation until cleared by a physician.”
• “It is essential that no athlete be allowed to return to participation when any symptoms persist, either at rest or exertion.”

Continued support for concussion-management recommendations in the NCAA Sports Medicine Handbook

• Student-athlete medical care and return-to-play decisions reside with individual colleges and universities and their medical team. 
• Once an athlete is completely asymptomatic, the return-to-play progression should occur in a stepwise fashion with gradual increments in physical exertion and risk of contact.