Concussions in

Youth Sports

Drew Nagele, PsyD, CBIS

Past President
Brain Injury Association of Pennsylvania
Director, Rehab Services
The Children’s Hospital of Philadelphia
• Got your Bell Rung!
• A Dinger!
• A Head Banger!
• Knocking the Cobwebs Loose!
• Seeing Stars!
• Punch Drunk!
• A Little Fuzzy!
• Just Shake it Off!

• Why do we sometimes see STARS when we hit our heads?

• What is going on in the brain when it gets jostled with high force?
 A Concussion is a Traumatic Brain Injury!
EACH YEAR – thousands of athletes in
Pennsylvania sustain CONCUSSIONS!
ƒ Concussion is defined as a trauma‐
induced alteration in mental status
(dazed, disoriented, confused)
ƒ May or may not involve loss of
consciousness
ƒ Can result in loss of memory for events immediately
before or after trauma
ƒ Can result in local neurological deficits that may or may
not be transient
Rate of Concussion
Per 1000 Athlete‐exposures*
• WITH HELMETS
– Ice hockey 0.27
– Football 0.25
– M Lacrosse 0.19
– W Softball 0.11
– Baseball 0.07

• WITHOUT HELMETS
– M Soccer 0.25
– W Soccer 0.24
– Field hockey 0.20
– Wrestling 0.20
– W Lacrosse 0.16
* Defined as one athlete participating in one practice or game
National Health Interview Survey
(1991)

• 1.54 million TBI a year

• 20% due to sports/recreation
– 300,000 annually
– 34% saw no physician
– 55% outpatient Rx only
– 12% hospitalized
National Electronic Injury
Surveillance System (1995)
• 216,259 ER cases
• 111,018 from all
competitive sports
– 23,908 Basketball (22%)
– 20,583 Baseball (19%)
– 20,128 Football(18%)
• 105,241 from other
recreation activity
– 39,265 Playground (37%)
– 16,106 Swimming (15%)
– 14,414 Skiing (14%)
What Happens in the Brain
During a Concussion?
Following
CONCUSSION
there are
actual
PHYSICAL, METABOLIC, AND CHEMICAL
CHANGES that may take place in the brain:
skull fracture
cortical contusion
subdural hematoma
epidural hematoma
intracerebral hematoma
** diffuse axonal injury **
cerebral edema
 What causes these changes in the brain?

Pattern of Injury Focal Injury Diffuse Injury

Mechanism of Injury Contact Forces Inertial Forces Inertial Forces

(Translational (Rotational
Acceleration) Acceleration)

Skull Fracture
Types of Injury ContraCoup Contusion Concussion
Epidural Hematoma
Intracerebral Hematoma Diffuse Axonal Injury
Coup Contusion
Subdural Hematoma Subarachnoid Hemorrhage
Subdural Hematoma
Intraventricular Hemorrhage
Tissue Tear Hemorrhage
Gliding Contusion
Injury From Translational Forces
Diffuse Axonal Injury
•Rotational stress/strain results in deformation
forces, which concentrate at points of
transition between regions with different
mechanical properties:
•Midbrain-cerebrum
interface

•Gray-white
matter
interfa
ce

•Corp
us
callosu
m
Diffuse Axonal Injury
•Cell death may not occur immediately, but is
the result of cascade of events set off by the
initial forces

•The initial trauma produces a breakdown of

the neurofilament inside the cell

•Cell is unable to maintain its structure and

over the next several hours after the initial
trauma: ¾ plasma
leaks into
the axon
¾ axon
enlarges
Diffuse Axonal
Injury
Retraction balls form
within hours after
the initial blow
Diffuse Axonal
Injury
How shearing can
affect one cell while
neighboring cells
remain intact
Brain injury can occur
even if there is NO loss
of consciousness

Initial CT/ MRI likely to

be normal
“Misconception is that concussion occurs only when you
are ‘knocked out’…”
“More than 90% of concussions do not involve loss of
consciousness.”
“…that there is no such thing as a modest concussion.”
SIGNS OBSERVED BY COACHES ON SIDELINE
• appears to be dazed or stunned
• is confused about assignment/play
• forgets plays
• is unsure of game, score, or opponent
• moves clumsily
• answers questions slowly
• loses consciousness (even momentarily ‐ BUT DOES
NOT HAVE TO LOSE CONSCIOUSNESS!!!)
• shows behavior or personality change
• forgets plays/events prior to hit (retrograde)
• forgets plays/events after hit (anterograde)

Even 1 Symptom = CONCUSSION!!!

SYMPTOMS REPORTED BY ATHLETE
• headache
• nausea
• balance problems or dizziness
• double or fuzzy vision
• sensitivity to light or noise
• feeling sluggish
• feeling “foggy”
• change in sleep pattern
• concentration or memory problems
SYMPTOMS MAY GET WORSE WITH EXERTION
ANY 1 SYMPTOM = CONCUSSION
Concussion SIGNS OBSERVED BY SYMPTOMS REPORTED BY

Sideline
COACHING STAFF ATHLETE

Symptom • Appears dazed or

stunned
• Headache or “pressure”
in head

Evaluation & • Is confused about

assignment or position
Mental Status • Forgets sports plays
• •
Testing:
Is unsure of game,
score, or opponent
• Moves clumsily
•
•
Nausea or vomiting
Balance problems or
dizziness
Double or blurry vision
• Sensitivity to light
• Sensitivity to noise

Clipboard • Answers questions

slowly
• Feeling sluggish, hazy,
foggy, or groggy
example • Loses consciousness
(even briefly)
• Concentration or
memory problems
available • Shows behavior or
personality changes
• Confusion

from CDC • Can’t recall events prior • Does not “feel right”
to hit or fall
• Can’t recall events after
hit or fall
 ACTION PLAN
Concussion If you suspect that a player has a concussion, you
should take the following steps:
Sideline • Remove athlete from play.

Symptom • Ensure athlete is evaluated by an appropriate

health care professional. Do not try to judge the

Evaluation & •
seriousness of the injury yourself.
Inform athlete’s parents or guardians about the
Mental Status known or possible concussion and give them the
fact sheet on concussion.
Testing: • Allow athlete to return to play only with
permission from an appropriate health care
professional.
Clipboard • IMPORTANT PHONE NUMBERS
Hospital Name:
example Hospital Phone:
Hospital Name:
available Hospital Phone:
For immediate attention, CALL 911
from CDC If you think your athlete has sustained a concussion…
take him/her out of play, and seek the advice of a
health care professional experienced in evaluating for
concussion.
•Orientation
Ask the athlete the following questions:

What stadium is this?

What month is it?
What city is this?
What day is it?
Who is the opposing team?
•Anterograde Amnesia
Ask the athlete to remember the following words:
girl dog green
Go on to the next 2 sections (you will then come back
and ask them what were the 3 words?)

•Retrograde Amnesia
Ask the athlete the following questions:
• What happened in the prior quarter/period?
• What do you remember just prior to the hit?
• What was the score of the game prior to the hit?
• Do you remember the hit?
•Concentration
Ask the athlete to do the following:
1. Repeat the days of the week backward
(starting with today).
2. Repeat these numbers backward:
63 (36 is correct)
419 (914 is correct)

•Memory for New Information

Ask the athlete to repeat the three words from earlier:
girl dog green

Any FAILURE is considered sign of Concussion

RECOMMENDATIONS:

• NO athlete with a concussion should continue to play

or return to a game after sustaining a concussion.

• An athlete who has sustained a concussion should

cease doing any activity that causes the symptoms of a
concussion (e.g. headaches, dizziness, nausea, etc.) to
increase
New Concussion Management Guidelines
CIS Group, Vienna (2001), Prague (2004)
“Cornerstones of Concussion Management”

Removal of symptomatic athletes from play

Restriction from play while symptomatic
Graduated return to play (following exertion)
Recognition of differences in children
Neuro-cognitive testing recommended
Aubry, Cantu, Dvorak, Graf-Baumann, Johnston, Kelly, Lovell,
McCrory, Meeuwisse, Schasmasch, 2001. Clinical J. Sports Med.
When Can an Athlete Safely “Return to Play?”
• All Youth Sports Leagues should have specific
guidelines for coaches to follow for
Concussion Management:
¾ Must be Symptom Free at REST & during PHYSICAL
EXERTION! (exertion added gradually)
¾ Cleared by a physician or concussion specialist

• It is recommended that youth athletes should

sit out of practice & games
¾ AT LEAST 7-10 days during
which time they experience
No Symptoms
Getting A-Head of Concussion
P. Hossler and R. Savage (2006)
• Effects of concussions tend to
subside within 7‐14 days. Yet
many last 6 months to 1 year
or more ‐ there is no set time‐
line for concussion recovery

• Many athletes can fully recover from a concussion, but it

is essential that their brain be given time and they be
protected from further injury during this time

• Some percentage of athletes with concussion will have

persistent symptoms, and some (5%) will have lifelong
effects of their brain injury
A child’s brain is not fully
developed until they are
in their early 20’s . . .
Three things to remember before sending a
child athlete back to play:

1. Children, unlike college age or adult athletes

take LONGER TO RECOVER from concussions

2. Post Concussion Syndrome

can occur

3. Second Impact Syndrome

can occur
Later Signs of Concussion
Post-Concussion Syndrome
Decreased Processing Speed
Short‐Term Memory Impairment
Concentration/Attention Deficit
Irritability/Anxiety/Depression
Fatigue/Sleep Disturbance
General Feeling of “Fogginess”
Academic Difficulties
Persistent headache
Intolerance of Bright Lights and Noise
 MULTIPLE CONCUSSIONS
ADD UP OVER TIME!!!
• Troy Aikman

• Wayne Chrebet

• Muhammad Ali

• Mike Matheny

• Steve Young
What Are The Risks And Complications Of
Repeated Head Injuries?
Effects of Repeated Concussions are
Cumulative
• Cumulative neuroanatomic pathology

• Cumulative neuropsychological impairment

• Effects can be compounded

even when injuries are separated
in time by months or years
 History of Concussion =
Increased susceptibility to future
concussions
• Example: Risk of
concussion in a
football player is 4 to
6 times greater if
there is a prior
established history of
concussion
Famous Cases of Repeated Concussions
PAT La FONTAINE, pro hockey
‐ sixth career concussion in October 1996
‐ listed injured for 3 months (headaches, vision problems,
incoordination)
(Shoats, 1996)

ROGER STAUBACH, Hall of Fame football

‐ retired in 1979 after numerous concussions
(Coulburn, 1997)

MUHAMMED ALI, pro boxer

‐ suffers from symptoms of Parkinson’s disease
‐ numerous blows to the head
‐ the AAN called for a ban on boxing
(Coulburn, 1997)

BRETT LINDROS, pro hockey

‐ suffered a series of concussions
‐ forced to retire in May 1996 due to post concussion syndrome
Quotes from Athletes with Repeated
Concussions
“I could never really remember what took place the
entire game.”
‐ TROY AIKMAN, pro football
(Players Gather, 1995)

“I would get dazed, probably six times a year… I was

babbling in the huddle.”
‐ STEVE YOUNG, pro football
(Players Gather, 1995)
 Second Impact Syndrome (SIS)

• Athlete sustains an initial

head injury and then sustains
a second head injury before
symptoms from the first have
fully resolved.

McCrory PR. Neurology, 50(3) Mar 1998

Second Impact
Syndrome
True incidence of SIS is
unknown
17 probable cases
Males 16 ‐ 24 years old
Boxing, football, and ice
hockey
Outcome: Catastrophic
or fatal
DEBUNKING the MYTHS:
1. MYTH‐ If you let your athlete fall asleep after a concussion he
will die or fall into a coma and not wake up.
FACT ‐ Is he sleeping or is he unconscious? If your
child athlete is hard to wake up – that is a sign to take him to
the hospital.

2. MYTH‐ If your CAT Scan is Negative, you’re CLEAR!

FACT ‐ CT, MRI, and EEG scans only detect skull
fractures, swelling, and bleeding (if it is large enough).
Signs from concussions RARELY show up on these tests.
BUT, it is still important to get one! (WHY?)
3. MYTH‐ A Grade‐1 Concussion is NO BIG DEAL.
FACT: Grading concussions is OLD SCHOOL. They have found that
someone with a mild concussion can have the same effects as a
child who is knocked unconscious.

4. MYTH‐ You can tell when a football player has had a

concussion.
FACT‐ Over 90% of concussions are never reported to medical
personnel, the vast majority of symptoms cannot be seen by an
outside observer, and 50% have symptoms that last less than 2
hours.
5. MYTH ‐ Players understand what a concussion is.
FACT – 50% of college athletes don’t know concussions can have
negative consequences, and 2/3 of high school athletes who don’t
report concussions to their trainer don’t report it because they
don’t believe the injury is serious enough to mention.

6. MYTH‐ It is safe to return to the same game if a player recovers

from a concussion on the sideline
FACT ‐ Athletes that appear to fully recover from a concussion on
the sideline still show cognitive deficits on neuropsychological
testing 36 hours later, indicating it would not have been safe to
return them to play – because their brain has not healed.
7. MYTH – Child athletes bounce back from concussions faster than
adults, just like any other injury
FACT – Children actually require much more time to recover than
adults. One study found that while the average college athlete
recovered from their concussion in 3 days, it took high school
athletes 7 days to recover.

8. MYTH‐ If the bump goes OUT your fine.

If it goes in you’re NOT.
FACT‐ It’s not the bump that will
determine whether there is a
concussion.
9. MYTH‐ If an athlete suffers a concussion in a game, he’ll be
fine to play ‘next week.’
FACT –
ƒ 50% of high school athletes have not recovered
enough to safely return to contact 7 days later.
ƒ 30% have not recovered enough to return to
play 2 weeks later
ƒ 15% haven’t recovered enough to return to
play 3 weeks later
10. MYTH ‐ If an athlete doesn’t vomit or get sick to his stomach –
he doesn’t have a concussion.
FACT – Many children who vomit following concussion tend to
also be prone to motion sickness.
So if a child doesn’t vomit – that doesn’t mean he doesn’t have a
concussion!

11. MYTH ‐ If an athlete’s pupils are not dilated, he doesn’t have a

concussion.
FACT – It is not simply “pupil dilation” it is UNEQUAL PUPIL SIZE
that is ONE of MANY signs of a concussion, and does not have to
occur for a concussion to be present.
 Brain STEPS
Child & Adolescent Brain Injury
School Re-Entry Program

• Strategies
• Teaching
• Educators
• Parents
• Students
 Brain STEPS
Child & Adolescent Brain Injury
School Re-Entry Program

• establishes consulting teams available to

families and schools throughout
Pennsylvania

• teams are extensively trained in the

educational needs of students returning to
school following brain injury
 Brain STEPS
Child & Adolescent Brain Injury
School Re-Entry Program
• teams work with local school staff to develop
educational programs, academic interventions,
strategy implementation, and monitoring of
students

• teams consist of:

¾Educational professionals
¾Rehabilitation professionals
¾Family members of students with brain
injury
 If you have a youth athlete who experiences concussion, and
has persistent symptoms, refer to BrainSTEPS for help with
cognitive and physical symptoms that could impact educational
performance

Sarah Krusen MA CCC/SLP Brenda Eagan‐Brown, MSEd, CBIS

Bucks County IU Brain Injury Association of PA
Brain STEPS Team Coordinator BrainSTEPS Program Coordinator
215‐348‐2940 ext. 2085 724‐944‐6542
skrusen@bucksiu.org eaganbrown@biapa.org
CDC’s Concussion Tool Kit for Coaches
http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm
 CDC’s website for Youth Sports Injuries
http://www.cdc.gov/ConcussionInYouthSports/default.htm
Brain Injury Association of Pennsylvania

1-866-635-7097
Toll Free Brain Injury Resource Line

www.biapa.org