Sports Concussion: What to do if a Loved One Suffers

Sports Concussion

School and sports are in full swing across the nation, including football, cross country, basketball, etc.  Along with the start of these sports, there’s a heightened awareness of concussions and how to properly manage a concussion.   Athletes, coaches, parents, and family members need to be educated on what to do when a child suffers a concussion. They should know the effect it has on the athlete and the dangers of playing while the concussion is still ongoing.  Gone are the days of suck it up, power through, and smelling salts.  Now there is a when in doubt, sit it out mentality along with a safe graduated return to play protocol.

What is a concussion?

A concussion is a mild traumatic brain injury that alters the way your brain functions.  Concussions are usually caused by a blow to the head. However, they can also occur when the head and/or upper body are violently shaken, such as in a car crash.  Concussions can cause a loss of consciousness but not all do.  Concussions can affect everyone of all ages.  There are a large variety of symptoms, including:

• problems with headaches
• concentration
• memory
• judgment
• balance
• coordination

Symptoms may also not appear right away and could have a delayed onset.

Steps/Guidelines to follow when an athlete suffers a concussion – on or off the field – for return to play:

If an athlete suffers or is suspected to suffer a concussion while in a game, that athlete needs to be immediately removed from the game. They should not be allowed to return to play until cleared by a medical professional experienced in concussions.  This is also true when an athlete suffers a concussion off of the field.

As recommended by the Consensus Statement on Concussion in Sport:

After receiving a concussion diagnosis, the athlete needs to follow a graduated step-wise return to play protocol.

The steps are as follows:

1. In addition to not playing the game, the athlete needs to rest both physically and mentally.  This gives the brain time to recover from the concussion.  Once he/she is symptom-free, without the assistance of medication, then the athlete can move on to the next steps.
2. Light aerobic exercise, such as, walking, swimming, or stationary cycling.  No resistance training, such as, weight lifting should not be done during this step.   The goal is to increase the heart rate.
3. Sport-specific exercise, such as, skating drills in hockey and running drills in football and soccer.  No head impact activities should be done during this step.  The goal is to add movement.
4. Non-contact training drills, such as passing drills in football and ice hockey.  The athlete may also start progressive resistance training.  The goal is to increase and assess exercise, coordination, and cognitive load.
5. Full-contact practice, following medical clearance, the athlete may participate in normal training activities.  The goal is to restore confidence and assess functional skills by coaching staff.
6. Return to normal gameplay.

Each step should take 24 hours. Therefore, it should take one week at a minimum before an athlete can return fully to play following a concussion.   During the return to play process, if the athlete becomes symptomatic at any step, then the athlete should drop back to the previous step. They are to try to progress to the next step again after 24 hours of rest.

Risks of not following guidelines:

Should the return-to-play protocol not be followed, there is a risk of second-impact syndrome. Playing and exerting the brain that is still undergoing a concussion can result in residual and permanent damage and injuries, including death.  There are resources in Colorado for athletes and families who suffer from residual or ongoing effects of a concussion or brain injury. A great resource is the Brain Injury Alliance of Colorado.

Steps/Guidelines for return to school following a sports concussion:

Concussions can also lead to difficulties at school and cognitive activities can lead to an increase in symptoms.  Thus, if needed, there is a recommended graduated return to school protocol as well:

1. Participate in daily activities at home that do not give the child symptoms or increase symptoms. These activities include reading, texting, and screen time.  Start with 5-15 minutes at a time and gradually build up the duration.
2. Participate in school activities, such as homework, reading, or other cognitive activities outside of the classroom to increase tolerance to cognitive work.
3. Return to school part-time for gradual introduction to school work and may need to increase breaks during the day.
4. Return to school full-time while gradually progressing school activities until a full day can be tolerated.[1]

Where do the guidelines for concussion in sports and return to play/school come from?

Over the years, there have been numerous and evolving guidelines and consensus statements that have become an integral part of the care provided to concussed athletes.  In 2001, the First International Symposium on Concussion in Sport was held in Vienna, Austria.[2]

The symposium aimed to provide recommendations for the improvement of safety and health of athletes who suffer concussive injuries in sports. During the symposium, a persuasive argument was made that a comprehensive systemic approach to concussion would be of potential benefit to aid the injured athlete and direct management of decisions.[3]

Since that time, the International Symposium has been held numerous times. Each time it provides an update to build on the principles outlined in the previous documents. It develops a further conceptual understanding of using the formal consensus-based approach to returning an athlete to play post-concussion.  The next symposium is set to take place in October 2022.

Additionally, states have enacted laws regarding concussions and return to play for youth athletes.  In Colorado, the Jake Snakenberg Youth Sports Concussion Act was enacted in 2011.

The Act provides:

(1)(a) Each public and private middle school, junior high school, and high school shall require each coach of a youth athletic activity that involves interscholastic play to complete an annual concussion recognition education course.

(b) Each private club or public recreation facility and each athletic league that sponsors youth athletic activities shall require each volunteer coach for a youth athletic activity and each coach with whom the club, facility, or league directly contracts, formally engages, or employs who coaches a youth athletic activity to complete an annual concussion recognition education course.

(2)(a) The concussion recognition education course required by subsection (1) of this section shall include the following:

(I) Information on how to recognize the signs and symptoms of a concussion;

(II) The necessity of obtaining proper medical attention for a person suspected of having a concussion;  and

(III) Information on the nature and risk of concussions, including the danger of continuing to play after sustaining a concussion and the proper method of allowing a youth athlete who has sustained a concussion to return to athletic activity.

(b) An organization or association of which a school or school district is a member may designate specific education courses as sufficient to meet the requirements of subsection (1) of this section.

(3) If a coach who is required to complete concussion recognition education pursuant to subsection (1) of this section suspects that a youth athlete has sustained a concussion following an observed or suspected blow to the head or body in a game, competition, or practice, the coach shall immediately remove the athlete from the game, competition, or practice.

(4)(a) If a youth athlete is removed from play pursuant to subsection (3) of this section and the signs and symptoms cannot be readily explained by a condition other than concussion, the school coach or private or public recreational facility’s designated personnel shall notify the athlete’s parent or legal guardian and shall not permit the youth athlete to return to play or participate in any supervised team activities involving physical exertion, including games, competitions, or practices, until he or she is evaluated by a health care provider and receives written clearance to return to play from the health care provider.  The healthcare provider evaluating a youth athlete suspected of having a concussion or brain injury may be a volunteer.

(b) Notwithstanding the provisions of paragraph (a) of this subsection (4), a doctor of chiropractic with training and specialization in concussion evaluation and management may evaluate and provide clearance to return to play for an athlete who is part of the United States Olympic training program.

(c) After a concussed athlete has been evaluated and received clearance to return to play from a health care provider, an organization or association of which a school or school district is a member, a private or public school, a private club, a public recreation facility, or an athletic league may allow a registered athletic trainer with specific knowledge of the athlete’s condition to manage the athlete’s graduated return to play.

C.R.S. §25-43-103.

Finally, many organizations and institutions have issued their own Return to Play Rules, Procedures, and Protocols to ensure the safety of their athletes. At times they will modify the standard of care to fit their sport and organization.  For example, many professional sports teams, such as Major League Soccer, have a written protocol for managing concussions and return to play.  The Major League Soccer Protocol modifies the graduated return to play steps identified below by adding Heading Drills. This is a skill specific to soccer that involves contact with the head.

Additionally, many colleges are required to follow the guidelines and procedures set forth by the National Collegiate Athletic Association (“NCAA”). The NCAA has set forth guidelines on concussion diagnosis and management best practices.  The NCAA advocates for collegiate institutions to make their own Concussion Management Plan, provide NCAA Concussion Fact Sheets to their athletes, coaches, team physicians, athletic trainers, and athletic directors, to have a pre-participation baseline concussion assessment, etc.  Additionally, many other sports organizations and high schools have set forth their own policies and procedures.  It is important to be educated on the requirements to ensure the athlete is safe to return to play.

Conclusion

Fortunately, many concussions are mild in nature. By following the above guidelines, athletes are likely to fully recover from the concussion and symptoms. Then they will be able to return to play their favorite sport fully.  When in doubt, set it out.  Athletes should miss a few games and follow the protocol fully. It’s better than ending up severely and permanently injured or worse.

If you or anyone you know suffered a brain injury as a result of the actions or inactions of another person, please contact brain injury attorney Amanda Pfeil-Hood. 

[1] McCrory P, Meeuwisse W, Dvorak J, et al. 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 2017;51:838-847.

[2] Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1^st International Symposium on Concussion in Sport, Vienna 2011. Clin J Sport Med 2002:12:6-11.

[3] Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1^st International Symposium on Concussion in Sport, Vienna 2011. Clin J Sport Med 2002:12:6-11.