Concussion Guidelines 

INITIAL RESPONSE

Coaches and other team personnel need to improve their ability to recognize the signs of concussion. Players themselves are often not able to acknowledge and report their own symptoms for a variety of reasons. A culture of safety among all athletes should be encouraged so that they can serve as important sources of information relating to a teammate that has been concussed.

Sideline evaluation

If an athlete is suspected of having a concussion it will be important to assess in some uniform way their physical, cognitive and subjective functioning. Any concern about spinal injury, prolonged unconsciousness or declining mental or physical functioning warrants immediate medical attention. When assessing cognitive skills it is preferred to use a consistent and objective method to evaluate orientation, attention, concentration and memory. Consider downloading and using the two-sided Sport Concussion Assessment Tool 5 (SCAT6) updated during the Amsterdam (2022) Concussion in Sport Group meeting:

If any symptom is present, cognitive, physical or subjective, remove the athlete from the game or practice and arrange to have a clinician experienced with sports concussions formally evaluate the athlete before they are allowed to return to practice or to play. The National Federation of High School Associations in September 2009 modified their concussion guidelines to prohibit a player from returning to play after a suspected concussion even if their symptoms resolve within 15 minutes. They must first be cleared medically and then complete a stepwise return-to-play process.

When in doubt, sit them out

Younger athletes have been shown to be more vulnerable to the effects of concussions; they take more time to recover and may be uniquely susceptible to the potentially life-threatening Second Impact Syndrome. Athletes to CDC (2024) Heads-up: Athletes emphasizes that it continuing to play when symptomatic increases the risk of further concussion.

INJURY MANAGEMENT

A plan of care should be comprehensive and coordinated; this will provide the most effective means to adequately care for a concussed athlete. This will include both a medical evaluation to rule out severe pathology, such as a bleed inside the skull, and neuropsychological assessment. Neuropsychological testing is clinically useful, cost-effective and readily available. In fact, the first Concussion in Sport Group (2001) labeled neuropsychology as “one of the cornerstones of concussion evaluation”, a statement that has been supported with each subsequent CISG meeting and Neuropsychological evaluation has been promoted by the National Athletic Trainers’ Association (2004, 2014) position papers. Such services are most useful when there is baseline data for that particular athlete that can be used for direct comparison. However, neuropsychological testing can also be very useful even in those cases where pre-injury information has not been obtained by comparing post-injury performance against comparable normative expectations.

Post-injury neuropsychological evaluation

Preferably within 24 to 48 hours of injury to assist with the determination of severity and to assist in crafting an appropriate and individualized treatment plan. All post-injury raw data are directly compared to that athlete’s individual baseline level of performance, if available, to determine recovery from injury. If baseline data are absent, post-injury results will be compared to an age- and gender-matched normative sample although this generally requires a more conservative interpretation of the findings.

During the recovery time

It is imperative for the athlete to avoid strenuous physical activities that may exacerbate their symptoms. On occasion, it may also be beneficial to restrict cognitive demands as well, such as a brief excuse from school or exams. Many times athletes who attempt to play through a concussion or return to activity too quickly will aggravate their symptoms, extend their recovery time and actually prolong their time away from the game. Proper concussion management is not anti-sport; the goal is to return the athlete to play as quickly and as safely as possible.

Follow-up neuropsychological evaluations

These may be needed to track recovery and modify treatment recommendations until the athlete can be determined to be without cognitive, physical or subjective symptoms at rest. The timing of these evaluations will be determined individually and will be based on factors such as injury severity, concussion history, age of the athlete, etc. Results are confidential but will be shared with the appropriate clinical staff and parents in order to provide the most comprehensive level of care for the injured athlete.

RETURN TO PLAY

Neuropsychology has a central role to play in managing sports-related concussions and is best used as an important component within a multidisciplinary treatment approach that will involve the athlete, parents, coaches, athletic trainers and medical doctors. Ideally, the athlete is ready to participate in a supervised return to play process when the treatment team as a whole has agreed that the athlete is symptom free at rest.

Tolerate physical challenges. Athletes are expected to complete increasingly demanding physical activities without symptoms before returning to play. Typically, each step will occur on a separate day and may require several days depending on the athlete and their injury factors. Any return of symptoms ends the activity and the athlete is rested until the next day when they resume their last successful step.

1. No activity, complete rest.
2. Light aerobic exercise such as walking or stationary cycling.
3. Sport-specific training, such as skating in hockey and running in soccer.
4. Non-contact training drills.
5. Full contact training after medical clearance
6. Competitive game play.

PROBLEM SIGNS

Crossroads. While the main focus of a Concussion Safety Program is to allow the athlete to recover and return to play if desired there are issues that, when present, may indicate a need to discuss whether returning to play is truly in the athlete’s best interest. There has been research that has indicated that athletes have an increased risk of further concussions once they have suffered an initial injury and some studies have shown that repeated concussions can have cumulative effects. Other research has suggested that there may be genetic factors in some individuals that produce greater sensitivity to the effects of concussion in general. Career-ending discussions are never entered into lightly and should include open conversations with all parties who are involved with the athlete.

Some potential indicators that the athlete has developed greater vulnerability:

• Concussions are occurring more frequently
• Concussions are occurring as the result of lesser impacts and forces
• Longer recovery times are required with each subsequent injury
• Greater interference with non-sports tasks, such as school, job performance, social function, interpersonal relationships, etc.

RISK REDUCTION

PRE-INJURY

Most concussive injuries are the unintended consequences of physical play – therefore, complete prevention is impossible. However, there are some approaches that may minimize the risk of occurrence.

• Proper safety equipment
• Proper fit of equipment
• No intentional head contact in games such as ice hockey and lacrosse
• Proper sports techniques, such as safe tackling in football, checking in ice hockey and heading in soccer
• Respect for opponents and for the game

POST-INJURY

No more “dings”. Players should not be encouraged to “shake it off” or return to play when still having symptoms. Once a concussion has happened, the best way to reduce the risk of compounding problems, prolonging recovery or worse (Second Impact Syndrome) is to recognize the injury, respond appropriately and have it managed thoroughly by an experienced team of clinicians. Second Impact Syndrome is believed to occur when a young athlete suffers another blow to the head or body while they are still symptomatic from a previous concussion, which results in severe brain swelling (cerebral edema) that often leads to permanent damage.

Avoid compounding the problem. Education of the signs and symptoms of concussion and proper recognition of injuries when they occur is paramount. Neuropsychological testing has been demonstrated to detect concussions more accurately than symptom reporting alone (Van Kampen, et al., 2006) and provides objective data about appropriate activities and return to play. The main message of the CDC (2017) is that proper management is the key for a thorough recovery and a good outcome athletically, academically and socially.