What is a Concussion?

The U.S. Centers for Disease Control and Prevention (CDC) defines a concussion as a brain injury induced by traumatic biomechanical forces secondary to direct or indirect forces to the head,19 which force the soft tissues of the brain into the skull. A direct force means that the skull comes in contact with another surface, such as the ground or another player, whereas indirect force involves no impact, but is caused by the sudden deceleration of the body, such as a car accident or other whiplash-like motions of the head. Also known as a mild traumatic brain injury (MTBI), concussions can occur with or without a loss of consciousness and range in severity. Regardless of the severity, every impact to the head is serious and demands thorough evaluation and adequate recovery time.

A recent study analyzing the amount and severity of hits to the head in three NCAA Division I football teams found that over the course of a season, each team, in practice alone, averaged 2,500 significant blows to the head, 300 of which were in the concussive range.20 The study used the Head Impact Telemetry System, placing accelerometers in players' helmets to measure the impact on the skull. This is an astonishing number of concussive and sub-concussive blows for an individual team, considering that game competition is not included in these statistics. Numbers like this strongly demonstrate how prevalent this issue has become in the sporting world.

The CDC estimates that anywhere from 1.6 million to 3.8 million sports and recreation-related concussions occur each year in the United States, most of which go untreated by medical professionals. A person who sustains a TBI, or someone who sustains several MTBIs, is at high risk for lifelong physical, cognitive, and psychological impairment.21 Athletes who are not properly evaluated by medical professionals, or those who do not give themselves ample recovery time, are even more susceptible to further injury such as second impact syndrome, chronic traumatic encephalopathy, and dementia pugilistica.

Second Impact Syndrome

Second impact syndrome results when the brain suffers from a second concussion while still recovering from one prior. If a second concussion occurs while the brain is still recovering, more fluid rushes to the area, putting increased pressure on the skull. This can immediately cause permanent damage and death. This severe outcome can happen if a player returns to play that day or even weeks later if the brain has not fully recovered.

Chronic Traumatic Encephalopathy

There is growing evidence and research suggesting that players who sustain repeated concussions suffer far greater long-term consequences. Chronic traumatic encephalopathy (CTE), evidenced by neurofibulary tangles in the brain's cortex, is becoming a growing concern in sports, particularly in football. CTE is a progressive disease that can cause depression, memory loss, and premature Alzheimer's disease-like dementia. There is mounting evidence linking CTE to several deaths of former NFL players who have received countless concussive and sub-concussive blows.22

Dementia Pugilistica

Another neurodegenerative disease that is increasingly common among athletes is dementia pugilistica (DP). DP, also known as chronic boxer's encephalopathy or boxer's dementia, is similar to CTE in that it develops progressively over time. People suffering from DP may have declining mental ability, speech problems, lack of coordination, tremors, and Parkinson's Disease.23

The brain is a highly complex organ and should be considered the most fragile part of the body, and therefore requires an appropriate amount of caution after suffering an injury. Rushing athletes who are suspected of having a concussion back to play without professional evaluation is not only negligent, but also can result in serious, permanent brain damage. To preserve the health and safety or our athletes, we must educate ourselves on how to better prevent and respond to concussions.



Coaches and parents must teach proper technique, such as hitting the core of a player with your head up in football or rolling out correctly while diving for a volleyball. More importantly, coaches and parents must encourage players to follow rules and safety precautions strictly. Ensure that safety equipment fits properly, has been maintained and is worn consistently.

Furthermore, coaches, parents and athletes must take the initiative to instill the importance of sportsmanship in our sporting community. Sports are not the ruthless games they are sometimes portrayed to be. Athletes at elite levels are more often not those who hit harder, but rather those who hit smarter. Playing smarter with self-discipline and control will reduce injuries and advance athletes to higher levels. If a concussion does occur, the athlete should not return to play until cleared by a medical professional.


Proper Diagnosis and Evaluation

Many teams and schools are now conducting computer-based neuro-psychological assessments prior to the start of a sports season. These tests measure an athlete's cognitive ability and set a baseline for testing brain function. For example, some test questions may include how quickly a player can do simple math or the ability to recall a list of objects in order.24 25 Later in the season, these same neuropsychological tests can be an effective follow-up tool for assessing a player's condition. For a post injury neuro-psychological test to be informative, it is imperative to have a comparative pre-injury assessment at the beginning of the season.

Every mind is wired differently and, therefore, the presence or absence of concussion symptoms varies greatly from athlete to athlete. For this reason, great time and care must be taken when evaluating the severity of an athlete's concussion, especially because symptoms are often subtle.

Coaches, parents, and players can prevent further injury by educating themselves on what to look for in an athlete suspected of having a concussion.

The signs and symptoms typically fall into four categories; physical, cognitive, emotional, and sleep. Some symptoms may appear immediately, while others may develop over days and even weeks. These symptoms may be subtle and be difficult to fully recognize.


The most common signs and symptoms of a concussion include:

Appears dazed/stunned Headache
Confusion Nausea
Moves clumsily Balance problems/dizziness
Answers questions slowly Double/blurry vision
Personality/behavior changes Feeling sluggish
Forgets events before/after the hit Sensitivity to noise or light
Forgets plays Feeling groggy, sluggish or foggy
Unsure of game, score, or opponent Concentration/memory problem
Loses consciousness Confusion


When an athlete reports these signs and symptoms, it is a good indication that the player has suffered a concussion. Remember that players will often avoid reporting symptoms because they wish to keep playing. This is why it is of vital importance to educate players on the consequences of playing through a concussion; the short- and long-term consequences are simply too great. No matter how minor the symptoms seem to be, do not let the athlete return to play. New laws are prohibiting the return of an athlete to practice or competition without the approval of a medical professional.26

If a medical professional is present, have them evaluate the athlete thoroughly and objectively with use of neurological baseline tests, cognitive ability, physical and symptomatic signs, motor function or coordination, emotional response, and other diagnostic tools. An athletic trainer is often the healthcare person present on the sidelines during sporting competitions. They are there so that a skilled professional is present to make the difficult decision on behalf of the athlete.

In the absence of a medical professional, several resources provide free onsite concussion evaluation tools. An effective concussion evaluation tool will include a signs and symptoms checklist, a memory assessment, a cognitive assessment, and neurological screening for eye movement, pupils, speech, etc. The Sport Concussion Assessment Tool (SCAT-2)27 is a user-friendly and thorough onsite evaluation tool. It is strongly recommended that coaches become familiar with this tool and possibly receive training from a professional, such as an athletic trainer, to develop a comfort level and familiarity with the exam. Many people recommend simulating a concussive event examination to prepare for the real thing.


The following may be used as a general guide for safe and effective responses:


A=airway B=breathing C=circulation

  • Check the scene first for safety and then the athlete.
  • Call 911 or other emergency number as necessary.
  • Care for the injured athlete until medical personnel arrive.
  • When in doubt, sit them out.


Regardless of whether symptoms subside or not, it is always recommended that an athlete suspected of sustaining a concussion be taken to a hospital or healthcare professional for a full evaluation.


Ensuring Adequate Recovery Time

Athletes recovering from a concussion are at high risk for further or even permanent damage. As discussed earlier, second impact syndrome, CTE, and PD can be life-threatening and inflict serious short- and long-term injury. To prevent further injury, a medical professional must provide approval before an athlete can return to play.

Returning to play must be done in gradual steps. Complete physical and mental rest is needed until the player is asymptomatic, keeping in mind that athletes may show no signs at rest, but are unable to mimic sports activities without the return of symptoms. While physical rest is vital, mental rest, or a quiet mind, facilitates a more rapid recovery process. Therefore, the injured athlete should avoid activities such as texting, playing video games, and doing homework.

The following is a recommended progression chart for clearance to return to sport. The athlete should be symptom-free for 24 hours at each level before advancing to the next step, and if any symptoms occur at a particular level, the athlete should return to the previous one. This should be coordinated by a physician or certified athletic trainer.


1. No activity with complete physical and mental rest
2. Return to mental activity
3. Light aerobic exercise, staying at less than 70 percent of maximum heart rate
4. Sport-specific exercise drills
5. Non-contact training drills at normal intensity
6. Full-speed, contact practice
7. Return to play


An athlete who has sustained even a mild concussion should be cleared by a medical professional in writing before returning to play.