Sport-related concussions (SRC) can happen in any sport. This brain injury is more common in contact and collision sports like ice hockey, football, and rugby. Thanks to extensive clinical and lab research, we now understand much more about it. The best practices for dealing with SRCs continue to be updated. Although health professionals are the experts in diagnosing, it is important for coaches, teachers and parents to be able to spot the symptoms of an SRC and take appropriate initial action.

Checking for symptoms

When you ask Joshua what happened, he replies that he got his ‘bell rung.’ He does not recall exactly how it happened. He says his vision was blurry for a few minutes and he has a mild headache. Joshua insists that he is fine and wants to keep playing.

Red Flag Symptoms
If any of these signs are present, get immediate medical help or call an ambulance. neck pain or tenderness double vision weakness, tingling or burning in arms or legs a headache that is severe or getting worse seizures or convulsions loss of consciousness or deteriorating conscious state vomiting unusual behavior – aggression, restlessness or agitation
Evaluate visual clues	Ask about physical symptoms	Assess Orientation
Lying without moving immediately after the injury Slow to get up after a blow Disorientation or confusion Blank look Facial injury Difficulty with balance or movement, poor coordination	Dizziness, headache, nausea, vomiting, ringing in the ears, neck pain Vision changes (loss of field of vision, double or blurred vision,‘seeing lights’) Pressure in head, slurred speech, feeling ‘in a fog’ Sensitivity to light and/or sound Drowsiness, fatigue or low energy Balance problems Change in emotions including irritability, anger, sadness, anxiety	Slow to answer questions or follow directions, easily distracted Mistakes in playing behaviour (such as skating in the wrong direction or shooting on own net) Difficulty with memory and concentration Being unaware of time, date or place, the game period or score
Originally adapted from Heads Up for HITS handbook, with additions from The Concussion Recognition Tool 5.

A concussion usually occurs from a direct blow to the head, face, or neck.

A hit elsewhere on the body can also cause it, if force is transmitted to the head. Evaluating someone with a possible SRC can be challenging, as symptoms and signs (see sidebar) may change rapidly. Athletes tend to downplay symptoms and say they feel fine. If you are concerned, ask the athlete to grade himself on a scale of zero to 100 per cent. An athlete who admits to being less than 100 per cent is often more willing to explain why.

Certain symptoms are red flags, suggesting a need for urgent medical attention. If the player falls as a result of the blow, first check for spinal cord injury. Do not move the athlete unless you have been trained to do so.

When you assess Joshua, he is unable to recall the score of the game. He does not know what period it is, and cannot repeat all the months of the year in reverse order. His coordination seems okay. Although he has a headache, he says he is ready to play again. You are uncomfortable about letting him back in the game.

If you think concussion is a possibility, take action immediately.

Do not allow a player who has any signs of concussion to continue in the game.
Do not leave the player alone. Keep an eye out for new symptoms or a change in consciousness.
Do not allow the athlete to drink, take drugs or drive.
Have the player evaluated by a medical doctor as soon as possible.

Health care professionals use another tool, the SCAT5, to help identify concussion. The updated version now includes a 10-word list for checking for problems with memory. If an athlete reports any symptoms, regardless of severity, or if the SCAT5 assessment is abnormal in any way, the athlete should not return to training or competition. If no concerning nervous system symptoms are present, then diagnostic imaging such as x-rays or a CT scan of the head are not required.

Currently, there are no specific medical tests for diagnosing a SRC.

Recovery and returning to play

You decide to pull Joshua out of the game. His parents take him to the dressing room. After he has changed, they go to the hospital emergency room for further evaluation. The next day you phone Joshua. He tells you he slept badly, still has a headache and just does not feel right. Then he asks if he can practice this evening.

Safely returning to sports is a critical part of properly caring for a SRC. Until now, it was generally recommended that athletes who suffer a SRC not return to physical activity until the concussion symptoms are gone.

Returning to activity - step by step
Step 1	Keep activity at a level that does not make symptoms worse, with a gradual return to work and school until symptoms are completely gone.
Step 2	Low intensity aerobic exercise, such as stationary bicycling x 30 minutes at less than 50% maximum heart rate (HR).
Step 3	Slowly increase duration and effort, such as stationary cycling x 45 minutes at moderate intensity (60 to 75% max HR).
Step 4	Increase activity again, such as with stationary cycling x 60 minutes at moderate intensity (60 to 75% max HR), with 60 second maximum effort sprinting at minutes 15, 20 and 25.
Step 5	Return to sport-specific training activity or drills at low intensity x 45 minutes. No contact permitted if involved in a contact or collision sport.
Step 6	Increase duration and effort in sport-specific training activity or drills at higher intensity x 60 minutes. Some contact is permitted if involved in a contact or collision sport.
Step 7	Return to full training and competition.
Each step should take at least one day. If any concussion symptoms reoccur at any step, reduce activity to a level that does not bring on symptoms or make them worse. Symptoms lasting more than 14 days require assessment by a medical professional familiar with managing SRCs. Also seek medical attention if the athlete is not able to progress through the steps without bringing on symptoms. Players should first be symptom-free, and then able to return to play step by step. In addition, it is important to ask whether the athlete feels ready to go back to the same environment that caused the injury. Hesitancy or feeling tentative suggests that the athlete may not be fully recovered. Do not allow return to play until confidence has also returned.

However, the recommendation of the 2017 Consensus Statement on Concussion in Sport is different. Athletes should rest both mentally and physically for at least 24 to 48 hours. As well, avoid other activities, such as prolonged screen time (computer, cell phone and video games), listening to loud music, and watching movies. Such activities can make recovery longer.

After this period, athletes can start returning to physical and cognitive activities. Keep activity at a level that does not make concussion symptoms worse. This usually means starting physical activity (not training or racing) at a very low intensity for a short time. For instance, try walking or stationary bicycling at low intensity, for 10 to 15 minutes per day. You can slowly increase the intensity and duration of physical activity, as long as it does not increase symptoms. Keep in mind that during this phase of a concussion, work and school-related mental activities can also make symptoms worse. If this is the case, there are ways to modify work and school activities, which include taking frequent breaks, having a separate quiet area to work or study, or even taking time off work or school.

Most adults recover from a SRC after 10 to 14 days. Children and teenagers may take over four weeks to recover. During this time, neck pain, symptoms like dizziness or trouble with balance, and mental health symptoms should be addressed.

A health care practitioner who is familiar with managing these problems is best able to help. Many physiotherapists, chiropractors, osteopaths, massage therapists or psychologists may qualify.

Once symptoms resolve, gradually increase the volume, intensity and complexity of sport-specific training (see Returning to Activity sidebar).

Preventing future injury

Joshua returns to play after completing the steps. He does not have another concussion during the season. After practice one day, he asks whether he can prevent another concussion.

Given the nature of sports, it is not possible to prevent all concussions. However, there are ways to lower the risk and severity of a concussion.

For contact sports, full facial protection and a custom-fitted mouth guard that covers the molars should be considered. Research has shown that in comparison to a half-face shield, a full-face version may reduce the severity of impact. Mouth guards protect the teeth, lips, gums and jaw. They may also shield against concussion by reducing the amount of force transmitted to the brain.

Check the age and fit of all equipment to be sure it offers the best possible protection. For instance, as the helmet worn when a concussion happened may be weakened, replace it.

Concussions are a possibility in sport, especially in activities involving contact. Recognizing an injury early and managing it properly protects the player’s health. Understanding the signs and symptoms of concussion should be a priority for athletes, parents and coaches.

For more detailed information about concussion in sport, please check:
The Canadian Concussion Collaborative	Concussion Recognition Tool 5	SCAT5 – Sport Concussion Assessment Tool 5

Concussion in Sport Protecting players from serious injury

Checking for symptoms

When you ask Joshua what happened, he replies that he got his ‘bell rung.’ He does not recall exactly how it happened. He says his vision was blurry for a few minutes and he has a mild headache. Joshua insists that he is fine and wants to keep playing.

Red Flag Symptoms

Evaluate visual clues

Ask about physical symptoms

Assess Orientation

Recovery and returning to play

Returning to activity - step by step

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Preventing future injury

Concussion in Sport
Protecting players from serious injury