Your son, daughter, athlete, or friend is in the middle of an intense game and they take a hard hit. You see them stumble off the field looking unsteady, you can tell something is wrong. What happens next?
The initial recognition of a concussion is critical to proper management. If the initial detection of a concussion is missed, and a player goes back in too early, they are at increased risk of cerebral edema or second impact syndrome which can have catastrophic implications. Players don’t always mention when they’ve “had their bell rung,” so it is often up to the coaches and athletic trainers to notice when something isn’t right. They will perform some sort of screening on the field to determine if there is a possibility of a concussion. If it is determined that there might be a concussion, the player should be out of the game and not cleared to return to any athletic activity within the same day.
After a concussion, there should be a follow up with a physician skilled in managing concussion symptoms, you usually a sports medicine doctor. Usually this happens relatively soon after the initial injury, within a few days. If there are more severe symptoms, such as worsening headaches, weakness or loss of coordination, slurred speech, repeated vomiting, or loss of consciousness a trip to the emergency room is needed for more urgent evaluation to reduce the risk of brain damage. If these symptoms are not present imaging is usually not needed.
Once the athlete is cleared from serious pathology a treatment plan is determined based on the level of symptoms and evaluation findings. Cognitive rest is important as it will allow the brain to reduce its activity and start to heal. Some people require complete cessation of all activity including school, reading, TV, phones, video games etc which is usually only a few days. Others may be able to continue functioning, but at a lower level as in half days or limited homework. Symptoms usually resolve mostly within 7-10 days. When symptoms have not resolved in 3 weeks, further evaluation may be needed by a physical therapist or other professional depending on the type of symptoms to determine what additional interventions may be needed as the concussion is not resolving on its own. Interventions may include further medical management, vestibular treatment, vision exercises, manual therapy, or graded exercise.
As symptoms resolve, the athlete will want to start getting back to activity. Although we want to get them back quickly, we also want this to be done safely. Athletes can only return to athletic activity after being cleared by a physician. If there is no physical testing done by the physician, it is up to you to pursue testing. There is a systematic process of increasing the exertional load and monitoring symptoms that can be performed to assess readiness to return to sports. Usually this occurs over the course of 5 days and gradually increases the intensity of exercises as long as there are no increases in symptoms and ends with activities simulating play. Then the athlete will resume play with practice, simulated play, then competitive play. Most athletes make a full recovery, but remember the history, as repeated concussions are more likely to lead to long term disability.