Safety First: Concussion Management and Return-to-Play Protocol

It’s no secret that concussions are one of the biggest issues in football. According to The Center for Disease Control, 1.6 to 3.8 million concussions occur annually in sports and recreational activities, making it an important public health issue. Unfortunately, as more high-profile athletes fall victim to concussions and as the number of concussions in football continues to rise, larger amounts of misinformation about proper prevention methods and return-to-play protocol spread.

It’s important to understand the facts when it comes to concussion management. Mistreatment of concussions can lead to greater injuries, such as permanent brain damage or even death. The younger the athlete, the greater the risk, so it’s important for parents and coaches to learn the proper protocol and not get absorbed in the misconceptions regarding return-to-play guidelines.

A concussion, by definition, is a traumatically induced alteration in brain function manifested by alteration in awareness and various signs and symptoms, such as headache, vertigo, hearing loss, and/or fatigue. They are caused either by a direct blow to the head, face or neck, or elsewhere on the body with an impulsive force transmitted to the head. When faced with a concussion, either as a player, coach, or parent, there are several important things to keep in mind:

There is no such thing as a “mild” concussion. Physicians do not label the magnitude of the concussion, but treat the injury and clear for play based on the individual in question. If there are any signs of concussion, no matter how slight, the player should be taken out of the game immediately. The player should not return to play the same day of injury and must receive the recommended graded return mandates several days away from contact activities. It’s important for coaches to tell their players to talk to a coach immediately if they feel they have been injured, especially if they feel that they have had their “bell rung.”
 
Every player sustaining concussion symptoms must be cleared by a physician before returning to play. In most states, legislation has been enacted ensuring that an athlete must be cleared by a physician in order to return to play after suffering any type of concussion. In New York, for example, a bill passed in 2011 requires a minimum 24-hour removal from play along with medical clearance from a licensed physician. Most physicians adhere to the Sport Concussion Assessment Tool (SCAT3) to clear the athlete for play. Along with identifying signs and symptoms, the SCAT3 tests a player’s cognitive and physical state, asking questions that determine their concentration, memory, and balance.
 
Concussion prevention strategies are in the process of being established. Adherence to proper blocking and tackling techniques is clearly important. The 2010 NFL rule change prohibiting players from tackling another player headfirst and using the head as a point of contact is an excellent example of changes that are being made. These adjustments are anticipated to lower the risk of concussions.

USA Football has undertaken a nationwide initiative to help youth football coaches make the game safer through concussion education and awareness and the introduction of proper technique in their “Heads Up” program. Coaches everywhere are more concerned about player safety and more aware of methods that can help reduce, if not eliminate, concussions.

Understand the difference between cognitive and absolute rest. Recent guidelines by the American Academy of Pediatrics outline the role of cognitive rest, stating that sometimes a temporary leave of absence from school, shortening of the school day, reduction of workload, and/or an allowance of more time to complete assignments or take tests may be necessary. However, absolute rest (no activity) longer than three days is usually not helpful and light aerobic exercise without contact has been shown to be helpful in individuals slow to recover. Resting for too long of a period can potentially lead to unwanted side effects such as depression, insomnia, and deconditioning. Reintegration into cognitive and physical activity should be gradual based on each individual’s condition with frequent monitoring. 

When it comes to making football a safer game, there is no more important development than the increasing awareness about concussions among the nation’s football coaches. Reducing concussions through better blocking and tackling technique and dealing with concussions by carefully following return-to-play guidelines will continue to ensure the game’s long-term health by providing a safer playing environment.


James Kinderknecht, MD, is a sports medicine physician at The Hospital for Special Surgery in New York City. He also serves as the medical director of the Public School Athletic League Football Clinic. Dr. Kinderknecht recently spoke on this topic at the 8th Annual Current Concepts in Sports Medicine symposium  in New York City, at a panel titled “Return to Play: Concussion Management, From Adolescent to the NFL.”