According to the Centers for Disease Control and Prevention (CDC), approximately 3.8 million sports-related concussions occur annually in the US. Many of these concussions will go undiagnosed, leading to mismanagement of symptoms. Missed concussion diagnoses also put athletes at risk of long-term consequences and delayed recovery.

Nicol McNiven, a physiotherapist at Evolution Physiotherapy, describes sports-related concussions as an injury with a lot of variables and a lot of unknowns. Alongside her work at the clinic, she dedicates her time to providing sports teams with on-field concussion management and injury prevention.

For this week’s blog post, we’ve summarized her perspective on sports-related concussions into a resource that covers how she spots a concussion, carries out an assessment, and directs return-to-play concussion protocol.

In our last blog post, Nicol outlined how a physical therapy approach to concussions and post-concussive syndrome can facilitate recovery, explaining everything from assessment to long-term treatment. Read our previous post on Physical Therapy & Concussions.

How to spot a concussion on the field

Spotting a concussion is critical; even if it’s a small hit, it can be incredibly detrimental for an athlete to continue playing after being concussed. 

It’s not always as obvious as a player getting knocked out cold – that’s hard to miss – sometimes contact can happen so quickly, the athlete barely even knows what’s happened. Plus, symptoms can have a delayed onset, so the concussed athlete doesn’t start feeling dizzy or nauseous until the game is over and they’re at home.

That means watching plays closely is important. Nicol recommends watching for two categories of head injury: head-on contact and contrecoup. Head-on contact is a direct impact hit and can be head-on-head, head-on-shoulder, or even head-on-equipment if there’s impact between a player and a goal post or stick.

Contrecoup is a form of whiplash. When an athlete gets hit, their head might fly back – this type of injury is where the brain moves inside the skull, causing trauma to the tissue opposite the site of the actual hit.

Nicol also recommends watching the players very closely after an impact. Loss of consciousness is a simple indicator of a concussion and is easy to spot. But often, players get concussed but don’t get knocked out.

Consider the following questions:

• How are they acting afterward?
• Are they stumbling or unbalanced?
• Are they confused or dazed?
• Are they looking through you instead of at you?

If it’s a soccer game, maybe the suspected concussed player isn’t following the ball or isn’t playing the correct position. This is where a coach’s knowledge can be very helpful because they know their players best and what their skill level is, so they can pinpoint unusual behavior – if they’re looking for it. 

What happens after the hit?

Once a player has been flagged as having a possible concussion, protocol kicks in. That means the player is pulled off the field for assessment. 

As a trained physiotherapist, Nicol uses a SCAT (Sports Concussion Assessment Tool). The SCAT is a standardized sideline concussion screening tool that helps both distinguish a concussion and the severity level of a concussion.

Symptoms to look for:

• Head pain/headaches
• Nausea or vomiting
• Feeling dazed
• Blurred vision
• Delayed response
• Slurred speech
• Emotional or irritable mood
• Loss of appetite or increased appetite
• Forgetfulness

These symptoms can present in many different ways; don’t expect consistency when it comes to concussions.

“I’ve had players that are crying, and they don’t know why.”

Nicol McNiven
Evolution Physiotherapy

Another critical point Nicol noted, is that the severity of symptoms upon impact does not necessarily indicate the severity of the full concussion. On-field concussion management professionals are also on the lookout for delayed concussion symptoms. 

A player could come off the field with a light headache that they don’t mention to their coach, then start feeling extremely nauseous half an hour, or even hours later. 

Red flags for Nicol are any symptoms that indicate the athlete should be sent to the hospital. Concussion red flags include:

• Tingling or numbness in limbs
• Neck pain
• Loss of consciousness
• Vomiting
• Worsening of any symptoms

Return-to-play Concussion Protocol

The average concussion for an adult clears within 2 weeks, and within 4 weeks for kids. Anything beyond those general timelines is leaning into post-concussive syndrome. 

There is a strict 6-stage protocol for returning to sport so athletes don’t start playing again too early and flare up their concussion in a situation that could potentially be dangerous. 

Each stage must be completed without causing physical or cognitive symptoms for at least 24hrs following the activity for the concussed patient to move to the next stage.

1. Activity
   Low-strain mental and physical tasks like walking around the house or cooking dinner.
   
   
2. Light Exercise
   This stage includes low cardio exercise like biking or walking a dog.
   
   
3. Moderate Activity
   Moderate activity can include sports-specific activities like dribbling for soccer players or shooting hoops for basketball players.
   
   
4. Heavy Activity
   This stage could be a full, non-contact practice including high aerobic activity and complex drills.
   
   
5. Contact Practice
   An athlete must be cleared by a physician to participate in this stage. Stage 5 is a full practice that includes contact.
   
   
6. Competition
   If there were no symptoms following stage 5, the athlete is cleared to return to regular competition. The athlete should continue to monitor for symptoms.

“The hardest part with an athlete is the fact they become secluded from their team. And so, the more information we know about the athlete and [their] symptoms, the more we can integrate them into the sport so they can hit a milestone of being able to participate in practice at some capacity.”

Nicol McNiven
Evolution Physiotherapy

HOW TO PREVENT CONCUSSIONS IN SPORTS

Some words of advice from Nicol for athletes, coaches, or parents:

For contact sports or biking, make sure to wear a helmet. The condition of the helmet significantly affects its efficacy: it should fit well, have no cracks, and have no signs of wear on it. Some helmets are one-time use, so after an impact, it needs to be replaced. A lot of hockey helmets need to be certified every year, so check to see when yours expires. Check out this video showing the importance of wearing a helmet and taking appropriate preventative measures.

If you or the team you coach plays a contact sport, make sure they know how to do contact correctly. The teams Nicol works alongside spend hours learning how to do proper contact so, theoretically, head-on contact never needs to happen.

If there’s a hard surface like a goalpost on the playing field or rink, wrap them with some cushioning to soften any potential head-on collisions.

Unfortunately, not every concussion can be prevented. Accidents happen, but the more you know the better off you and your team will be. 

Managing concussions from the sidelines is more than a player knowing when to stop or a coach pulling them out. Watching play closely for concussions, speaking up, or paying attention to behavior are action items the entire team and their parents can be involved in.

ADDITIONAL RESOURCES: 

• For more information on SCAT: Sport Concussion Assessment Tool 5 (SCAT5)
• Access adult and child SCATs online: Sport Concussion Assessment Tool
• Danish Road Safety Council / Helmet has always been a good idea