Concussions can occur in any sport or situation, in any age group, and at any time. When trained medical personnel are not easily accessible, it is often a coach's responsibility to evaluate an injury and decide if an athlete should return to play or be seen for further medical care. When a player sustains a concussion, he or she should not return to that game or practice. Returning the following day or the following week should be at the discretion of the player's physician.

What Is a Concussion?

A common assumption is that an athlete must be "knocked out" to sustain a concussion. That is not true. Any change in mental status or function qualifies as a concussion. Unconsciousness is clearly a severe injury. Amnesia (loss of memory) following head trauma is a more severe sign of concussion. The classic "having your bell rung" commonly occurs and is often ignored, which is a serious oversight.

Recognizing a subtle concussion is extremely important in preventing the rare but deadly Second Impact Syndrome (SIS). SIS occurs when an athlete sustains a second blow to the head while still symptomatic from the first hit. The second blow might be relatively gentle (a slap can provide enough force) and may occur days or weeks later. The second blow can cause a sudden swelling of the brain that quickly leads (within two or three minutes) to unconsciousness or cardiac arrest. Fifty percent of players who sustain SIS die, and the rest have a very high risk of permanent brain damage.

How to Recognize Concussions

Symptoms of a concussion may include confusion, dizziness, nausea, vomiting, headache, blurred or double vision, vacant stare, ringing in the ears, a funny taste in the mouth, poor coordination, loss of balance, sensitivity to light and noise, flashing lights, personality changes including emotional instability/behavior (anger, crying, and anxiety), feeling sluggish, slurred speech, or loss of memory. It is important to recognize that most athletes won't necessarily come up to you and complain of these symptoms, so a responsible coach has to always be on the lookout for abnormal behaviors. Watch out for the athlete who just sits and stares, seems to be a step behind where he or she usually is, blows a routine play, or "just doesn't look right" to you. If you are at all suspicious that an athlete may have a concussion, immediately test him or her using the pocket card on the back. If any of these symptoms are present, remove your athlete from competition or practice even if he or she becomes completely normal later in the practice or game. Symptoms can recur for days after the initial injury and are a sign that the brain has not healed enough to participate in any athletic activity. If you notice any of these post-concussion syndrome symptoms in your athlete, report it to the athletic trainer, a parent or guardian, and/or a physician. In their desire to play, many athletes try to hide or minimize injuries. Be aware of changes or concerns reported by teammates or teachers. Post-concussion syndrome often has long-term effects that interfere with functioning at home, school, or work. If you suspect an athlete may have a concussion, he or she should be evaluated by a physician. When in doubt, sit them out!

Concussions and Return-to-Play Decisions

Recent research on athletes under 18 years of age has shown that even when they say they are normal after having shown symptoms after an initial concussion, brain function and reflexes may not return to normal for weeks in some athletes. If available, psychometric testing such as the IMPACT program may be helpful to assess when a player may return to play. If your athlete meets the criteria for having a concussion when you test him or her, remove the athlete from that game or practice and from all further athletic activity until a physician or certified athletic trainer clears him or her for such activity. Resist the parent or well-meaning bystander who may offer to make that choice for you. These guidelines are for the good of the student athlete, and are not negotiable under any circumstances.

There have been various grading scales to evaluate the seriousness of a concussion. According to guidelines established at an International Conference on Concussions in Sports in Vienna 2001, concussions are no longer graded; if a player has had head trauma and has sustained a concussion of any severity, the player cannot return to play on the day of the concussion. Those grading scales have been found not to be useful to determine when a player can return to play.

Regardless of the recommendations of others, if your gut feeling tells you to bench a player, do not let anyone - players, parents, coaches, fans, or circumstances - change your mind. You are never wrong to keep a player out of a practice or game. It is the safest option. When in doubt, sit them out!

The athlete may be conscious at all times but is dazed, foggy, or fuzzy. The player may miss one or two items in the concentration test but shows no confusion or memory loss. The athlete may feel like he or she is just "kind of out of it" or off balance. These are the concussions where the symptoms can "clear" in 15 to 20 minutes. But there may still be injury occurring in the adolescent brain, and recommendations now are to treat these young players more conservatively than in athletes over the age of 18.

If a player suffers a second concussion in the same season, returning to play should be more conservative than after the first such incident. As with the first concussion, the player should not return to athletic activity until they have been seen and cleared for return to play by a physician. No matter how minor the head injury, notify the family about it and indicate what symptoms to look for (see PDF  CONCUSSION INFORMATION CARD). Do not rely on the athlete to communicate this information. A responsible person needs to watch for delayed problems.

The athlete should have no symptoms (subjective findings as expressed by the player such as headache, feeling groggy, or foggy) or signs (objective findings that are seen by another observer, such as the player moving clumsily or appearing stunned or dazed) of a concussion. Any amnesia (memory loss) is a critical warning sign. For example, you may notice the athlete repeatedly asking the same questions without remembering that he or she asked them, or without remembering the answers. If an athlete misses any of the confusion/orientation or memory test questions, in addition to not returning to play, the player should seek emergency medical attention. He or she should not return to athletic activity for a minimum of five to seven days after all symptoms have disappeared and should be cleared first by a physician or certified athletic trainer. Rest is the only known method of treating concussions.

Any loss of consciousness, no matter how brief, is a concussion requiring immediate medical attention; therefore, there is no need for you to perform any exams. However, you must do the following:

• If the athlete wakes up within one minute and does not have any neck pain, you may move the athlete to the sideline, where you should keep him or her calm and quiet. Call an ambulance or ask a responsible adult to take the player directly to an emergency room.
• If the athlete is unconscious longer than one minute, does not wake up, or complains of neck pain after returning to consciousness, assume the athlete has a neck/spine injury. DO NOT move the athlete. DO NOT remove the player's helmet. Make sure that he or she is breathing. Do not allow others to move the athlete. Call an ambulance. While waiting for the ambulance to arrive, keep the athlete's head from being moved.

Return to play after a concussion should take place in a stepwise process after the player is free of all signs and symptoms of a concussion. The player can then proceed to the next level if he or she continues to be free of symptoms and signs at the current level. If any signs or symptoms recur, the player should drop back to the previous level and progress to the next level again after 24 hours.

Levels of activity:

1. No activity, complete rest
2. Light aerobic activity, exercise such as walking or stationary cycling
3. Sports-specific training such as skating
4. Non-contact training drills
5. Full-contact training after clearance by a sports medicine professional
6. Return to competition

Decreasing the Risk for Concussions

Is it possible to prevent concussions? More than half of football and hockey players report suffering concussions each season! You can do certain things that will decrease the risk for concussion.

This is a four-point program:

1. Wear a helmet certified for your sport. Make sure that the helmet fits tight so that it does not move around on your head. The helmet should be attached by a chin or neck strap.
2. Wear a mouthguard, preferably a mouthguard fitted by a dentist. There is no proof that the use of a mouthguard decreases the risk for concussions, but it may be useful in certain situations.
3. Hydrate. A hydrated player makes better decisions and can make better plays. A hydrated player may also have a decreased risk for head trauma.
4. Think ahead. Players should be aware of what is going on in the field or on the ice. A player should not put his or her head in situations that may lead to a concussion.