Concussions have been around ever since people could move, particularly in competitive group settings like sports. While colloquial expressions (e.g. “he got his bell rung” or “she saw stars”) are often used to describe when someone hits his/her head, it is important to be clear that concussions are traumatic brain injuries. They may fall anywhere on the continuum from mild to severe, but they are still traumatic brain injuries and need to be assessed and treated appropriately. It is also important to note that not all instances of head impact result in a concussion. Until this is ruled out, however, it is critical to act on the side of safety and not allow someone to continue playing if he/she has sustained a blow to the head and has one or more of the following:

1. Symptoms reported by the player (e.g. headache, nausea)

2. Signs observed by someone else (e.g. unsteadiness)

3. Impaired brain function (e.g. confusion)

4. Abnormal behavior. The phrase “when in doubt, sit it out” is a good one to remember.

Most of the time, a concussion will fully heal and brain function will return to normal given adequate time and physical and mental rest. If an athlete return’s to play before a concussion is fully healed, however, there is significant risk for “second impact syndrome (SIS).” While rare, SIS happens because a second concussion occurs before a first concussion is resolved and it involves rapid swelling of the brain that leads to permanent disability or possibly death. Adolescents are most at risk for SIS.

The recent youth concussion legislation that Governor O’Malley signed into law in May 2011 was prompted by a case of SIS that occurred to a middle school athlete in Washington State in 2006. Zackery Lystedt was a 13 year old football player who hit his head during a play then remained down, clutching his helmet and rolling his head back and forth in pain. He was taken out of the game but went back in for the second half. He hit his head again and had to be airlifted for emergency surgery for a life-threatening brain hemorrhage. His road to recovery was long–7 days on a ventilator, 3 months in a coma, several months of rehabilitation, 9 months until he could speak a word, 13 months until he could move a limb, 20 months on a feeding tube and 3 years until he could stand with assistance. Permanently disabled, he and his family are dedicated to raising awareness and ensuring appropriate management of concussions so a similar fate does not befall other young athletes. As of summer 2013, 49 states (Mississippi is the lone exception) and the District of Columbia have adopted legislation to support the goals of what has become known as the Lystedt Law.

When a youth is suspected of having a concussion, there is a stepwise approach to returning him/her to play. This progression aims to identify any symptoms at increasing levels of exertion. If symptoms are noted, activity is immediately stopped. Once the player has rested and been symptom-free for 24 hours, he/she can try the level of activity at which symptoms were observed. Each step requires generally 24 hours without symptoms before advancing to the next step.

Baseline (Step 0): As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 24 hours.  Keep in mind, the younger the athlete, the more conservative the treatment.

Step 1: Light Aerobic Exercise
The Goal: only to increase an athlete’s heart rate.
The Time: 5 to 10 minutes.
The Activities: exercise bike, walking, or light jogging.
Absolutely no weight lifting, jumping or hard running.

Step 2: Moderate Exercise
The Goal: limited body and head movement.
The Time: Reduced from typical routine.
The Activities: moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting

Step 3: Non-contact Exercise
The Goal: more intense but non-contact
The Time: Close to Typical Routine
The Activities: running, high-intensity stationary biking, the player’s regular weightlifting routine and non-contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Practice
The Goal: Reintegrate in full contact practice.

Step 5: Play
The Goal: Return to competition


A few final points to keep in mind are that concussions can occur in any activity setting, to include contact and non-contact sports, recreation activities and accidental blows to the head. Symptoms can be mild and can be delayed. Contrary to former belief, fewer than 10% of concussions include a loss of consciousness.

One of the very best things we can do for our children is to support them being active. Exercise and activity tones muscles, strengthens hearts, reduces stress, improves sleep, increases confidence and can be great fun. However, participating in exercise and activity is not without risk–strains, sprains, bruises, scrapes and muscle soreness are all part of the game and just as we attend to those, we must attend to the possibility of concussion. If suspected, it is crucial to allow for appropriate time and rest before returning to play. It is the head’s up way to keep kids in the game–healthy and ready to play.

For more information on concussion awareness, to include sideline assessment tools, see

For more stories of concussion survivors (to include Zackery Lystedt), see

– Megan Richardson, Family Nurse Practitioner

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