You Think You Have a Concussion. What Next?

Know what steps to follow if you think you or your athlete is showing signs of a concussion.

To be clear this article is by no means a way to diagnosis and treat a head injury, nor is it an attempt at providing medical advice of any kind. This is entirely meant as an informative article aimed for parents, athletes or coaches who have never dealt with a head injury before. If you or a loved one suspects a concussion, get it treated by a medical professional. Do not play with a concussion as Second Impact Syndrome is more likely to occur.

As a certified athletic trainer, I have unfortunately seen my fair share of concussions. Over the course of my career, I do not think I have ever seen two concussions that are exactly the same. This subject is an extremely intricate topic with many different aspects. For now, let's just focus on what happens once there is a mechanism of injury that is cause for suspicion of concussion.

The Initial Diagnosis Is a Concussion

You were just informed that you have a concussion. How did a medical professional come to this conclusion?

There are actually several tools one might use to diagnosis a concussion. The most common on-field assessment used is the Sports Concussion Assessment Tool (SCAT) developed by the Sport Concussion Group. This form has been updated multiple times, most recently in spring of 2017, making the current version SCAT5. This assessment tool combines the use of symptoms reported by the athlete, a cognitive assessment, a balance assessment, a coordination assessment, an orientation assessment (where are you physically and where are you in time), behavioral assessment and lastly, a memory assessment.

It also includes a portion for observed symptoms. A clinician would also possibly use an ImPACT test after the game once access to a computer is possible. The ImPACT test is a medical device that is FDA approved for use in the diagnosis and the management of concussions. Both assessment tools are better when a baseline test exists for the athlete, as that allows the clinician to compare your pre-injury results with your post-injury results. If there is no baseline test, it's not a terrible thing, it just makes it slightly more difficult for the clinician.

What's Next?

Now that the diagnosis has been reached, you'll want to get a copy of the results so you can follow up with proper medical care when you get home (if your team has a certified athletic trainer or team physician, you'll likely be directed to them). The right doctor would be someone whose practice primarily deals with concussions. I have come across multiple physicians that have the majority of their practice in the treatment of sport concussions. Not all physicians are up to date on the management of concussions, as their speciality might be something entirely different. Your healthcare professional will know how to proceed and guide you through the process. This includes going over what to expect over the next couple of days following the concussion and how to proceed.

All states have different protocols about how a player proceeds post-concussion. In some states, if the injury happens in a high school game, you have to be cleared by a physician and follow a return-to-play protocol before your full return to play. There's a lot of variation in how states or governing bodies treat concussions, which is why you need to speak with someone who is well-versed in your sport and state laws. Having a physician guide you through this process is always a good thing if you are in high school, as they are able to write notes for your teachers and school. This should make it less difficult to deal with all the red tape that can be caused by a head injury.

To return to play, you must first become symptom-free. How long is this going to take? That depends on many variables like your age, sleep patterns, possible previous-medical conditions and previous history of concussions.

The Symptoms are Gone. Now What?

Let's say some time has passed and your symptoms have cleared. Now what?

In the NCAA, they have begun having concussed athletes return to the classroom before returning to sport. Since a concussion is an injury to the brain, it not only affects physical abilities, but cognitive/mental abilities, as well. How do you return to class? The same way one would return to play. That means a "graduated return" where you start off easy and work up to your full workload only if your symptoms do not return.

Who is it that will guide you through this process? It should be led by your physician or team athletic trainer, who will know your specific state's laws, your sport's guidelines, and most importantly your own needs.

As for graduated return to play, I will be outlining the play protocol made by a panel of leading experts during the 5th International Conference on Concussions in Sports. The first step is to just go about everyday life, self-limiting your activities to those that do not cause your symptoms to get worse or provoke your symptoms. This generally means gradually working to a full return to work or school. The second step would be light aerobic activities that slightly elevate your heart rate, like riding a stationary bike. There should be no weightlifting here, as it causes a larger increase in blood pressure and heart rate, which can provoke symptoms if done too early. Naturally, you need to remain symptom free for at least 24-48 hours after this before heading to the third step.

The third step is to begin sport-specific activities. These types of activities are considered to be running and/or skating drills. The intensity is higher than the previous step, but there is no risk of making any kind of contact. The fourth step is non-contact training. These include passing drills. During this phase, I like when the athletes wear a different colored penny (such as red) during drills, as that makes it more obvious for their teammates that they are not to make contact with you. If cleared by your healthcare professional, you may be able to begin weight training. However, you have to be cleared by the healthcare professional familiar with you and your specific case. The goal of this step is to help increase your mental thinking during sport, work on coordination, and just get in some significant exercise.

The final step is participating in a full contact practice. This means that you are able to participate in normal practices to restore your confidence and be assessed by coaches on your functional ability. Depending on the amount of time you have missed, you may need a few more practices to build up your cardio or re-sharpen your technical skills before making a return to the starting lineup. After this, your health care professional will clear you without restriction in most cases, and you'll be free to play in normal games or matches.

Hopefully this gives you a rough idea of what to expect when you or someone you care about sustains a concussion. As previously stated, this is not meant to be a medical guide. It's simply a way to educate people who may find themselves involved in this process. Education in head injuries is a huge benefit to people who play sports. If you suspect that you or someone you care about has a concussion, report it to the team's health care professional. If there is not one for your team, the coach and the athlete's parents should be made aware immediately. Do not try to play through a concussion, as it is more likely that you suffer from a condition known as Second Impact Syndrome. Do not allow an athlete to play if there is even a suspicion of a concussion! In most cases, athletes who sustain concussions are in the first third of their life. They have a lot of life left to live, and tending to their brain health is of the utmost importance. Even when the symptoms have seemed to clear up, there are several steps that need to be taken before the athlete can return to normal play. That means patience—from the player, from their teammates, from their coaches, from their teachers and from their healthcare professional—is absolutely pivotal when dealing with a concussion.

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