Introduction

Johns Hopkins University is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. In accordance with NCAA legislation, evidence-based management guidelines, and the Centers for Disease Control and Prevention, Johns Hopkins University has adopted the following Concussion Safety Protocol for all NCAA student-athletes. This protocol identifies expectations for institutional concussion management practices as they relate to (1)  the definition of sport-related concussion*; (2) independent medical care*; (3) preseason education; (4) pre-participation  assessment; (5) recognition and diagnosis; (6) initial suspected concussion evaluation; (7) post-concussion management; (8) return-to-learn; (9) return-to-sport; (10) limiting exposure to head trauma; and (11) written certificate of compliance signed by the athletics health care administrator.

1. Definition of Sport-Related Concussion*

The Consensus Statement on Concussion in Sport, which resulted from the 5th international conference on concussion in sport, defines sport-related concussion as follows:
Sport-related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized to clinically define the nature of a concussion head injury include:

• SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
• SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
• SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
• SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.
• The clinical signs and symptoms cannot be explained by drug, alcohol or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors or coexisting medical conditions).

2. Independent Medical Care*

As required by NCAA Independent Medical Care legislation, team physicians and athletic trainers shall have unchallengeable autonomous authority to determine medical management and return-to-activity decisions, including those pertaining to concussion and head trauma injuries, for all student-athletes.

3. Preseason Education

All NCAA student-athletes will be provided and allowed an opportunity to discuss the NCAA Concussion Education Fact Sheet and be required to sign an acknowledgement titled “Student Athlete Concussion Statement”, on an annual basis and prior to participation, that they have been provided, reviewed and understood the concussion education material.  

All coaches, team physicians, athletic trainers, directors of athletics and other athletics personnel involved in NCAA student-athlete health and safety decision making will be provided and allowed an opportunity to discuss the NCAA Concussion Education Fact Sheet and be required to sign an acknowledgement titled “Admin/Staff/Coach Concussion Statement” on an annual basis, that they have been provided, reviewed and understood the concussion education material. 

4. Pre-Participation Assessment

All NCAA student-athletes will undergo a pre-participation baseline concussion assessment. This pre-participation assessment will be conducted at Johns Hopkins University and, at a minimum, will include assessment for the following:

• History of concussion or brain injury, neurologic disorder, and mental health symptoms and disorders. Implemented in new athlete medical history questionnaire
• Symptom evaluation Implemented utilizing SWAY (annually)
• Balance evaluation. Implemented utilizing SWAY(annually)
• Cognitive assessment. Implemented utilizing ImPACT (bi-annually)

The team physician will determine pre-participation clearance and any need for additional consultation or testing and will consider for a new baseline concussion assessment at six months or beyond for any NCAA student-athlete with a documented concussion, especially those with complicated or multiple concussion history.

5. Recognition and Diagnosis of Concussion

Medical personnel with training in the diagnosis, treatment and initial management of acute concussion will be present at all NCAA competitions in the following contact/collision sports: basketball; field hockey; football; lacrosse; pole vault; soccer; and wrestling.
    NOTE: To be present means to be on site at the campus or arena of the competition. 
                Medical personnel with training in the diagnosis, treatment and initial management of acute concussion will be available at all NCAA practices in the following                 contact/collision sports: basketball; field hockey; football; lacrosse; pole vault; soccer; and wrestling.
    NOTE: To be available means that, at a minimum, medical personnel can be contacted at any time during the practice via telephone, messaging, email, beeper or other                 immediate communication means and that the case can be discussed through such communication, and immediate arrangements can be made for the athlete to be                 evaluated.
 Any NCAA student-athlete that exhibits signs, symptoms or behaviors consistent with concussion:

• Will be removed from practice or competition for evaluation.
• Will be evaluated by an athletic trainer or team physician (or physician designee) with concussion experience.
• Will be removed and prohibited from practice/play for that calendar day if concussion is confirmed/diagnosed or suspected.
• Will only return to play the same day if the athletic trainer, team physician or physician designee determines that concussion is no longer suspected.

6. Initial Suspected Concussion Evaluation

The initial concussion evaluation will include:

• Clinical assessment for cervical spine trauma, skull fracture, intracranial bleed and catastrophic injury.
• Symptom assessment. Implemented utilizing a SCAT5.
• Physical and neurological exam. Implemented utilizing a SCAT5.
• Cognitive assessment. Implemented utilizing a SCAT5.
• Balance exam. Implemented utilizing a SCAT5.

7. Post-concussion Management

Activation of emergency action plan⁺, including immediate assessment for any of the following scenarios:

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• Prolonged loss of consciousness.
• Focal neurological deficit suggesting intracranial trauma.
• Repetitive emesis.
• Persistently diminished/worsening mental status or other neurological signs/symptoms.
• Spine injury.

                    ⁺ Emergency action plan may require transportation for further medical care.
Because concussion may evolve or manifest over time, for all suspected or diagnosed concussions, there will be in place a mechanism for serial evaluation of the student-athlete. The student athlete will follow up with the medical staff on a daily basis and fill out a ‘Post Concussion Symptom Scale’ to assess their progression until they return to full activity.

For all cases of diagnosed concussion, there must be documentation that post-concussion plan of care was communicated to both the student-athlete and another adult responsible for the student-athlete, in oral and/or written form. The student athlete and roommate/housemate will be sent home with written home care and emergency referral instructions the same day they are documented to have a concussion.

Any NCAA student-athlete with atypical presentation or persistent symptoms will be re-evaluated by a physician in order to consider additional diagnoses, best management options, and consideration of referral. Additional diagnoses may include, among others: fatigue and/or sleep disorder; migraine or other headache disorders; mental health symptoms and disorders; ocular dysfunction; vestibular dysfunction; cognitive impairment and autonomic dysfunction.

8 Return-to-Learn

Returning to academic activities after a concussion is a parallel concept to returning to sport after concussion. Cognitive activities require brain energy utilization and after concussion, brain energy may not be available to perform normal cognitive exertion and function. The return-to-learn concept should follow an individualized and step-wise process overseen by a point person within the athletics department, who will navigate return-to-learn with the student-athlete and, in more complex cases of prolonged return-to-learn, work in conjunction with a multidisciplinary team.

When a student athlete has sustained a concussion the JHU Return to Learn Protocol will be initiated (See attachment below). This starts with the athletic trainer contacting via email the Team Physician, Athletics Healthcare Administrator, Assistant Director of Student-Athlete Success, Assistant Athletic Director for Compliance, Director of Student Outreach and Support, and the Director of Student Disability Services (Multidisciplinary Team). The Assistant Director of Student Athlete Success is the point person who will navigate the student athlete through the return to learn process, working with the student athlete and the student’s professors to coordinate an individualized initial plan to manage the academic course work while the student athlete is recovering at home/dorm from the concussion to ensure a gradual return to the classroom and studying as tolerated. The student athlete will be instructed not to attend classes for 24 – 48 hours post diagnosis of the concussion.

A student-athlete who has suffered a concussion will return to classroom/studying only as tolerated with modification of schedule/academic accommodations, as indicated, with help from the Assistant Director of Student Athlete Success. Campus resources will be engaged for cases that cannot be managed through schedule modification/academic accommodations. The Assistant Director of Student Athlete Success will also coordinate with Student Disabilities Services, under the direction of the office of ADAAA, to meet with the student athlete and provide accommodations to ensure student athlete success for cases that cannot be managed through schedule modification/academic accommodations.

A student-athlete will be re-evaluated by a team physician (or their designee) if concussion symptoms worsen with academic challenges or in the event of atypical presentation or persistent symptoms lasting longer than two weeks. The Team Physician will consider referral to neuropsychologist or additional specialist for treatment. Once the student athlete has returned to full athletic participation, the athletic trainer will alert the Assistant Director of Student-Athlete Success that student athlete has returned to full participation.

9. Return-to-Sport

Unrestricted return-to-sport should not occur prior to unrestricted return-to-learn for concussions diagnosed while the student-athlete is enrolled in classes. Final determination of unrestricted return-to-sport of an NCAA student athlete diagnosed with a concussion will be made by a Johns Hopkins University team physician following implementation of an individualized, supervised stepwise return-to-sport progression.  Factors which should be taken into account include the student athlete’s age, concussion history, migraine/headache history, seizure history, history of learning disabilities and mental health history. Once a student athlete is sign and symptom free for 24 to 48 hours, he/she will undergo an exertion trial and progression under the supervision of the certified athletic trainer. If the student athlete remains asymptomatic, he/she will progress as follows and will be reassessed on each day that includes: 

1. Symptom-limited activity.(only utilized at discretion of team physician)
   1. Consists of cardiovascular activity after 48-72hrs.post injury as long as signs and symptoms do not increase after the activity.
2. Symptom Free: Trial- 20 to 30 minutes of non-contact light aerobic exercise without resistance training.
   1. Following the trial of light aerobic exercise, asymptomatic student athletes will be ImPACT tested and a SWAY test will be performed.
   2. If the student athlete continues to state that they are symptom free despite ImPACT/SWAY testing that suggests that he/she has not returned to baseline, additional post-injury ImPACT/SWAY testing may be deemed necessary)
3. Symptom Free: over 60 minutes of sport-specific exercise and activity without head impact.
4. Symptom Free: Non-contact practice with progressive resistance training.
5. Symptom Free: Unrestricted training.
6. Symptom Free: Unrestricted return-to-sport.

The above stepwise progression will be supervised by a health care provider with expertise in concussion, with it being typical for each step in the progression to last at least 24 hours.

NOTE: If at any point the student-athlete becomes symptomatic (more symptomatic than baseline), the team physician or physician designee will be notified, and adjustments will be made to the return-to-sport progression. *

10. Limiting Exposure to Head Trauma

Johns Hopkins University is committed to protecting the health of and providing a safe environment for each of its participating NCAA student-athletes. To this end and in accordance with NCAA association-wide policy, Johns Hopkins University will limit student-athlete head trauma exposure in a manner consistent with Interassociation Recommendations: Preventing Catastrophic Injury and Death in Collegiate Athletes. For example:

• Johns Hopkins University teams will adhere to existing ethical standards in all practices and competitions.
• Using playing or protective equipment (including the helmet) as a weapon will be prohibited during all practices and competitions.
• Deliberately inflicting injury on another player will be prohibited in all practices and competitions.
• All playing and protective equipment (including helmets), as applicable, will meet relevant equipment safety standards and related certification requirements.
• School Name will keep the head out of blocking and tackling in contact/collision, helmeted practices and competitions.