Concussion Testing Protocols and C3 Logix System

The College of Idaho Athletic Training Department along with St. Luke's Intermountain Orthopedics has worked to improve assessment and recognition of concussions and mild brain trauma of its athletes. The Impact program has been a major part of concussion management for The College of Idaho athletic programs by providing neurocognitive data for its athlete's and is an important tool in the assessment of concussions and other types of mild brain trauma. As the advancement in technology and medicine continues, it is necessary for the athletic training staff and medical clinicians who work with the athletes at The College if Idaho to utilize and adopt advancements in technology for concussion testing and management when possible.

C3 Logix provides reliable indicators and objective measurements for the clinician to assess a concussion and significantly reduces the subjectivity of diagnosing a concussion by assessing six domains of brain function, combining the results into one program. It is by far the most complete program to date in the assessment of concussions. C3 Logix has also demonstrated the ability to diagnose other neurocognitive disorders in the clinical setting that are not related to mild brain trauma.

The C3 Logix Program combines computerized neurocognitive and memory testing assessment along with visual acuity, dynamic visual acuity, and balance testing. It will give the athletic training department and team physician at the College of Idaho more objective data to diagnose a concussion or mild brain trauma, relying less on subjective data which is all too often based on the athlete's symptoms. Developed by the Cleveland Concussion Clinic, this comprehensive program combines the benefits of collecting data, such as mental skills, balance and motor skills, and other factors that are impaired when an athlete sustains a concussion. It is powerful, affordable, and easy to utilize. It is simple to interpret data for medical personnel and literally provides a clear "picture" for the athlete, coaching staff, and parents of the athlete to see the levels of brain impairment in those cases of mild brain trauma when compared to the baseline test.

The data is recorded in an IPad by the athletic training staff on the court or field of play then uploaded wirelessly to I-Comet (sometimes referred to as the Cloud) where it is accessible to the team physician and other select medical professionals that are involved in caring for the athlete with a possible concussion. The chances of testing poorly or "sand bagging" a baseline test, which has been reported during other computerized neurocognitive testing, is greatly diminished, since the medical team at The College of Idaho is administering the test for each individual athlete. It has also been demonstrated through testing in the clinical setting it is difficult for the athlete to intentionally skew the results in all six domains. Total time required to administer each test is approximately 16-17 minutes per athlete however the mass baseline testing program provided by C3 Logix can be reduce the time per test significantly. This may seem labor intensive initially, but with the aid and support of the athletic staff and other health care providers for the college, such as Rehab Authority, it can be done quite effectively and efficiently.

The information provided in this policy is from Just Go Products, which is a direct distributer for C3 Logix. It is presented so the reader has a better understanding of the C3 Logix product for concussion testing as a part of the College of Idaho Mild Brain and Concussion Testing Policy and program .More information on this system can also be accessed from the C3 Logix web site, www.C3Logix.com, or the Cleveland Concussion Clinic.  

C3 Logix Multi-Factorial Approach - The Six Domains of Assessment

C3 Logix utilizes six different areas of assessment for baseline comparison. The following chart compares recommendations from the 2012 International Conference on Concussions in Sports (ICCS) along with the Impact Test and the components of C3 Logix.

The Multi-Factorial Approach
Recommendations from 2012 ICCS Impact Test C3 Logix
Graded Symptom Checklist Yes Yes
Reaction Time Yes Yes
Memory & Processing Speed Yes Yes
Motor Function No Yes
Vision No Yes
Balance No Yes
Vestibular Function No Yes

This concussion system is consistent and inclusive of all the recommendations of the ICCS, which includes neuro-motor, balance, and visual acuity assessments along with the graded symptom checklist. Other baseline assessment systems primarily focus only on neurocognitive measures such as reaction time, memory, and processing speed. The C3 Logix balance assessment utilizes an algorithm coupled with the high quality sensor array from the iPad system. The iPad is actually placed in a specially designed case that is placed on the athlete's back and held in place with a belt. The athlete is asked to perform each stance for 20 seconds with their eyes closed, objectively measuring each stance that represents a "quantitative mapping" of postural stability in the six different BESS stances.

Visual acuity, both static and dynamic testing is performed by having the athlete read a series of letters which appear on the IPad. If the athlete has less than three errors, the test continues. The letters are presented in smaller sizes for each successive test. Dynamic testing of visual acuity involves the use of a metronome, where the athlete rotates his or her head to the left and right side, focusing on the screen of the IPad, reading the letters as they appear. The size of the letters remain the same for each of the five tests for this domain.

The result of measuring all six areas is literally a complete pictorial representation of brain function. Data visualization utilized by C3 Logix is represented in Fig. 2 below.

figure 2

The outer sides of the pentagon represent the athlete's baseline test, with the inner portions representing testing following a concussion. Normative and statistical data are available for the clinician to examine as well.

Implementation of Testing Protocols for Concussion Management

Beginning in the fall of each academic year, athletes in collegiate athletic programs that are considered high risk or contact sports at The College of Idaho will receive a baseline test prior to their preseason conditioning programs. Baseline tests through the C3 Logix testing program are a part of the athlete's pre-participation physical examination (PPE) and will be obtained by the athletic training staff at the college every other year. These sports are listed below:

  • Baseball
  • Men's and Women's Basketball
  • Football
  • Men's and Women's Soccer
  • Men's and Women's Ski Teams

Physical therapists from Rehab Authority and other health care personnel designated by the athletic training room staff will also assist in administering baseline tests for those athletes in sports with large rosters. Sports such as baseball, basketball, football, and softball require mass baseline testing. Additional athletic staff and athletic training students can assist in directing athletes in the testing process.

The Baseline Testing Procedure

The C3 Logix testing procedure is divided into three stations. When the athlete arrives to the designated test sight, a bar code sticker is applied to each athlete, usually on the right or left upper chest area on their shirt, and will be scanned by the IPad for each portion of the baseline test. Because of the balance portion of the test, athletes will be asked to wear comfortable clothing, preferably athletic clothing, during baseline testing. In the first station, the athlete is instructed to enter their demographic data (Intake Module), then begin the neurocognitive portion in the first station on the IPad provided by the athletic training department. Scanning of the bar code allows athletes to go to any one of the clinicians or athletic training staff involved in administering the test in the next two stations, which are the visual acuity and balance modules. As a part of their service agreement, Just-Go Products can furnish additional IPads for the College of Idaho to use for mass baseline testing at no additional charge. They will be shipped to the college prior to the testing. The college will return the IPads once testing is complete. The college will pay a small shipping fee to return the IPads to Just-Go Products.

Data Collection

Date from baseline testing and subsequent testing following a mild brain injury will be uploaded into i-Comet, which is a massive storage database provided by the C3 Logix System, in conjunction with technologies provided by Apple. Access to this data will be limited to the the team physician and athletic training staff at the College of Idaho. Other health care providers involved in caring for the athlete who sustains a mild brain injury (neurologists, neurosurgeons, vestibular therapists, etc.) can also have access to data collected from the C3 Logix baseline test and subsequent follow up testing with a referral from the team physician and permission from the athlete. As with any medical information, the data collected from C3 Logix testing is subject to the HIPPA privacy laws related to medical information.

Management of Mild Brain Trauma and Concussions

The College of Idaho Team Physician, athletic training staff, and health care providers that work directly with the athletes at the college understand the importance of early recognition, management, and care of concussions and mild brain trauma. Many of the protocols and procedures highlighted in this document follow recommendations regarding management of mild brain trauma by the National Athletic Trainer's Association (NATA), the National Collegiate Athletic Association (NCAA), and the National Association of Intercollegiate Athletics (NAIA) as well as other allied medical organizations. Adoption of these policies and procedures is necessary to manage these types of injuries in an expedient manner.

  1. The athlete that is recognized by the athletic training or coaching staff as receiving a potential mild brain injury or concussion will be removed from the field of play. This athlete will be evaluated by the athletic training staff immediately following the injury episode if athletic staff is present. An athlete who sustains a possible mild brain injury where athletic training staff is not present should be directed to the athletic training office by the coaching staff as soon as possible.
  2. Athletes who are symptomatic and present with any post concussive symptoms related to a mild brain injury or concussion following a blow to the head will not be returned to practice or competition. The athlete will be reassessed by the athletic training staff to determine his or her medical status 24 hours after the injury event.
  3. A post-event assessment will be conducted and recorded by the athletic training staff utilizing the C3 Logix Testing Program. A determination of the athlete's medical status will be made by the team physician in conjunction with the athletic training staff, based on the athlete's current symptoms and results from the post-event assessment compared to the athlete's baseline test.
  4. The athlete will then be referred to the team physician for further evaluation and diagnosis as necessary. Referrals to the team physician for mild brain injuries or concussions, as with other athletic injuries, will be facilitated by the head athletic trainer in conjunction with athletic training staff.
  5. Further testing and activity restrictions will be placed on the athlete by the team physician based on additional assessments made by the team physician and recommendations of the athletic training staff at the College of Idaho, who will follow the athlete's status on a day-to-day basis. Any changes of the athlete's symptoms will be reported directly to the team physician by the athletic training staff. Referrals to neurologists, neurosurgeons, or other specialized therapy for the athlete who has been diagnosed as having a concussion will be made by the team physician.

Return-to-Play Protocols and Activity Restrictions for Mild Brain Injuries and Concussions

Athletes who are diagnosed as sustaining a mild brain injury or concussion will not be returned to physical activity as long as he or she presents with post-concussive symptoms and has not returned to their baseline status as measured by their individual C3 Logix test. The decision to begin implementation of these protocols for the athlete who sustains a concussion is at the discretion of the team physician. The athlete must remain asymptomatic at each stage of the return-to-play protocols in order to progress to the next stage. If symptoms return at any stage of the process, the athlete will be restricted to no activity status. The team physician will make all decisions as to when the athlete can begin any mild physical activity during recovery. There are five gradual steps to help safely return an athlete to play, adapted from the International Concussion Consensus Guidelines, and have been adopted by the team physician, athletic training department at the College of Idaho, and the Concussion Clinic at St. Luke’s Health Care System.

Return to Play Progression

Baseline (Step 0): As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 24 hours. Keep in mind, the younger the athlete, the more conservative the treatment.

Step 1: Light Aerobic Exercise
The Goal: only to increase an athlete’s heart rate.
The Time: 5 to 10 minutes.
The Activities: exercise bike, walking, or light jogging.
Absolutely no weight lifting, jumping or hard running.

Step 2: Moderate Exercise
The Goal: limited body and head movement.
The Time: Reduced from typical routine
The Activities: moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting

Step 3: Non-contact Exercise
The Goal: more intense but non-contact
The Time: Close to Typical Routine
The Activities: running, high-intensity stationary biking, the player’s regular weightlifting routine, and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Practice
The Goal: Reintegrate in full contact practice.

Step 5: Play
The Goal: Return to competition

Protocol for those C of I students who are not participating in athletics:

  1. If an incident requires immediate medical attention, the student would be taken to an emergency room.
  2. If the student is seen in the emergency room, and is diagnosed with a possible concussion, the student would notify the College of Idaho nurse’s office, and they would in turn notify the Department of Learning Support and Disability Services.
  3. The LSDS office would notify St. Luke’s Concussion Clinic recommending a student contact them for further concussion evaluation. It is the student’s choice to communicate with St. Luke’s, and it is St. Luke’s policy that students with concussion concerns contact them directly. If connection is made, the clinic will then collect pertinent information, and make a determination as to the next steps taken.
  4. If both parties deem it necessary, St. Luke’s Concussion Clinic would refer the student to an appropriate physician for continued diagnosis. The student can then follow through with the physician referred in regards to completing a concussion screening. If there is a concussion diagnosis, the doctor would provide the student with a recovery and accommodation form. The student would then bring this form to the LSDS office. At this point, the Director of Disability Services can follow similar procedures/protocol that are taken with C of I athletes. (The recovery and accommodation form brought back from doctors referred by St. Luke’s Concussion Clinic is in harmony with our “Concussion Zone” policy at College of Idaho. At this point, the Department of Learning Support and Disability Services can follow this procedure, which allows smooth transition for notifying professors, setting up accommodations, etc.).
  5. The student should continue follow up with the referring physician, and keep Disability Services informed of their status so that the LSDS office can keep professors informed.
  6. It is the student’s responsibility to maintain contact with the referred doctor, and to attend required appointments. If the procedure for follow up is not maintained, services through the LSDS department can be in jeopardy.

Following an incident, and the student does not go to the emergency room:

    The student would come to the College of Idaho nurse’s office. If the nurse believes there is evidence of concussion concerns, he/she nurse would then bring the student to the Office of Learning Support and Disability Services. Steps 3 through 7 above would then be followed.

Note: The non-athlete concussion procedure does require the student to provide their own insurance when seeing an emergency room or referring physician.

Academic Considerations for the Student with a Mild Brain Injury

A concussion has a significant impact on cognitive functions of the brain, which will have significant impact on his or her performance in the classroom. Moreover, increased mental stimulation of the brain can prolong or worsen symptoms, therefore prolonging recovery from mild brain trauma. Cognitive rest has been overlooked in the treatment of a concussion; however it has been demonstrated to have a definitive medical benefit in the recovery of mild brain trauma. In fact those who undertake cognitive activity restriction recover faster and have reduced possibility of symptoms returning, which is an indication of the brain’s dysfunctional metabolism following a concussion. The goal is to provide "reasonable academic accommodations" for the student that has suffered mild brain trauma. The College of Idaho has adopted "Post-Concussion Disability Accommodations," which will be included as part of the policies for the Learning Support and Disability Services Department. These accommodations can be applied for any student who has sustained a concussion that has been properly diagnosed by a physician or other qualified medical professional.

Once a student has been diagnosed by a physician as sustaining a concussion, medical documentation will be provided to the student. He or she will meet with the office of Learning Support and Disability Services to discuss the extent of the injury, based on documentation provided to the student by the a physician, with specific academic accommodations. The following is a zone management concept for academic management and strategies based on the student’s medical status following a concussion or mild brain trauma.

Post-Concussion Disability Accommodations

This system is designed for academic professionals to understand the implications of mild brain injury as it relates to the student’s academic performance in the classroom. Once students are diagnosed, a personalized instructional strategy for the impaired student can be implemented. This personalized education program is based on the student’s daily academic progress and is implemented by the professor or instructor for each class the student attends. Both physical and social behaviors can also be monitored in the classroom by the professor or instructor, which are indicators of the student’s progress, since these behaviors are indicative of neurocognitive function and recovery. The student is assigned the lowest zone any one professor or the LSDS office determines based on observation and evaluation. A student may perform to pre-concussion ability with no instructional strategies in place in one or more classes as each concussion will manifest differently in each student.

A zone, which is designated by a color, is assigned based on student’s most significant limitation in any one class. The definition is based on combination of physical classroom attendance and what is referred to as mental attendance (e.g. classroom participation, responding to verbal questions from students/instructors, appropriate social interaction). These can be monitored by academic professionals in a classroom setting.

Zone Definition Instructional Strategies EMAIL Language
Initial Suspicion/Day of Trauma Student attendance and participation may be impacted as a result of the injury. Modifications to the student’s academic day may vary from class to class and the Zone indicated is determined by the most significant symptoms occurring in any class. Initial Suspicion of Concussion Email: This student is currently being evaluated for a concussion. Symptoms associated with this type of injury may include, but are not limited to headache, dizziness, difficulty concentrating, fatigue, fogginess, sensitivity to light & noise, changes in social or academic interaction and difficulty reading. Symptoms may become pronounced later in the day and/or may return with higher level thinking tasks and cognitive exertion. Please let us know if you notice any changes in this student’s academic or social behavior in your class, as this will assist us in determining the follow-up care they receive.
1 - Red No School

Symptomatic at Rest
  • Not attending school
This student has suffered a concussion and is currently resting both cognitively and physically at home. This student has been instructed to avoid all academic work and to avoid any symptom exacerbation. Upon their return to your class, they may not have all assignments up to date and also will probably need to reduce the pace or quantity of work for several days. We will provide an update following their next clinical evaluation. Upon return to school, the student and teacher will need to discuss any missed work and upcoming assignments to develop a plan that encourages gradual completion of assignments as recovery progresses.
2 - Orange Limited school day

Limited Physical class attendance
  • Student class attendance limited
  • Clear Desk, meaning no written desk work (auditory only)
  • Limited Classwork
  • Peer note taking
  • Student may benefit from periodic breaks from active classroom participation (head down on desk)
This student is under continued monitoring for a concussion by the athletic training staff. They may be attending partial school days and/or need to limit the amount of time in a particular class and will most likely not have completed some assignments. Students in this recovery zone may benefit from the following instructional strategies:
  • Rest breaks during class
    • Head down in class or seated with eyes closed not actively working, but actively listening
  • Rest in health room for up to 20 minutes
  • Limited classwork/testing
    • Less reading, more listening
    • Utilize teacher or peer notes
  • Develop and maintain a schedule for completing assignments
Please be observant of any changes in the student’s physical or cognitive activity when they return to your class and share any concerns with appropriate staff members (athletic trainer, counselor, administrator, etc). In addition, please communicate with the student about their progress so they can feel comfortable and confident about returning to school, participating in class, completing assignments and sharing information with you related to their recovery.
3 - Yellow Student attends full day of school

Limited class time with possible partial mental class attendance
  • Clear Desk
  • Classroom participation as tolerated
  • Limited Classwork
  • Student may need period of mental and/or physical rest within the classroom (head down on desk)
This student will be attempting to complete a full school day but may need to limit time attending any class that causes concussion symptoms to resurface and/or intensify. Depending on the class content, time of day, and method of instruction, the following instructional strategies may provide the greatest benefit to the student:
  • Rest breaks during class
    • Head down in class or seated with eyes closed not actively working, but actively listening
  • Rest in health room for up to 20 minutes
  • Adjusting amounts of classwork/testing
    • Emphasis on formative rather than summative assessments
    • Develop and maintain a schedule for completing assignments
Please continue communicating with the student regarding assignments, class participation and their overall recovery. Please contact the counselor and/or athletic training staff if you have any questions.
4 - Blue Full class attendance (both mental and physical) with instructional strategies
  • Student attends full class
  • Instructional strategies in use Relevance of instructional strategies to be determined by the teacher as appropriate for each individual student’s needs
This student should be attending a full school day and be in attendance for and participating in the entire class period with minimal instructional strategies in place, including:
  • Adjusting amounts of classwork/testing, including summative assessments
  • Actively working on completing missed assignments
These instructional strategies may be utilized to reduce any residual concussion symptoms and foster the most appropriate learning environment during the final stages of the student’s recovery. Please alert the counselor and/or athletic training staff if the student is not able to maintain classroom attendance due to concussion symptoms.
5 - Green Full class attendance without instructional strategies
  • No instructional strategies needed
This student should be participating fully in class at this time and is scheduled to begin a return to athletic participation/increased physical activity. Before we do, we are asking for any input or concern that you as the teacher might have about this student based on your classroom observation as they have progressed through the concussion recovery. Please alert the athletic training staff if the student continues to utilize any instructional strategies to minimize concussion symptom exacerbation. The student should be actively working on, or have completed any make up work as appropriate.
Post Follow-up 1 - 3 weeks post return to unrestricted activity
  • Verification that student is performing at pre-concussion level cognitively in classroom
This student has recently recovered from a concussion and has returned to unrestricted cognitive and physical activity. We would like to verify that this student has returned to their pre-concussion academic ability in your class. Please respond using the link below to confirm or comment on their recovery.