A Parent's/Guardian's Guide to Concussion (NFHS)

A PARENT’S / GUARDIAN’S GUIDE TO CONCUSSION

National Federation of State High School Associations (NFHS)

Sports Medicine Advisory Committee (SMAC)

What is a concussion?

 A concussion is a traumatic brain injury that interferes with the normal function of the brain.

Concussions were previously referred to as a “ding” or a “bell-ringer” but this undermines the

seriousness of problem. Any suspected concussion must be taken very seriously. An athlete does not

need to lose consciousness (be “knocked-out”) to suffer a concussion. In fact, less than 5% of

concussed athletes suffer a loss of consciousness.

Concussion Facts

 Structural injuries, like torn ligaments and broken bones, can be seen on an x-ray or on scans like an

MRI. On the other hand, a concussion is a disruption of how the brain works, or its function, and not in

its structure. That is why CAT scans and MRIs are typically normal. The injury affects the way the brain

works, not how it looks.

 It is estimated that over 300,000 high school athletes across the United States suffer a concussion each

year. (Data from the NFHS Injury Surveillance System, “High School RIO

”)

 Concussions can happen in any sport. While they are more common in sports that involve collisions,

athletes in all sports are at risk for a concussion. When researchers looked at 14 different high school

sports, they found that over two-thirds of concussions result from contact with another athlete and the

second leading cause of concussion, is player-to-surface contact. This includes falling and hitting the

ground.

 An athlete may report many physical, behavioral, and cognitive symptoms. Physical symptoms include

headaches, nausea, vomiting, dizziness, and sleep changes. Some behavioral changes include

irritability, anxiety, and depression. Cognitive symptoms are changes in the way we think and include

feeling sluggish, hazy, or foggy, difficulty concentrating or memory problems, and confusion.

 Many symptoms appear immediately after the injury, while others may develop over the next several

days. The symptoms can interfere with normal daily life in addition to difficulty with school, work, and

social life.

 Concussion symptoms may last from a few days to several months. It is important to remember that

each student athlete responds and recovers differently.

 Athletes should not return to sports or activities that will put them at risk for another head injury until

the concussion has completely resolved. To do so puts them at risk for worsening and prolonged

symptoms and a more severe injury. While rare, a repeat concussion can also result in severe swelling

and bleeding in the brain. This condition can lead to death or permanent disability.

What should I do if I think my child has had a concussion?

If your child sustains a head injury, it is good to be aware of the signs and symptoms of a concussion. If you

suspect an athlete has a concussion, the athlete must be immediately removed from activity. Continuing to

participate in a contact or collision sport while experiencing concussion symptoms can lead to worsening of

symptoms, increased risk for further injury and sometimes death.

Parents and coaches should not make the diagnosis of a concussion. Any athlete suspected of having a

concussion should be evaluated by a medical professional trained in the diagnosis and management of

concussions.

When in doubt, sit them out!

All athletes who sustain a concussion need to be evaluated by an appropriate health-care professional who is

experienced in concussion management. If your child's school has an athletic trainer (AT), please inform the

AT of your concerns. You should also call your child’s primary care provider and explain what has happened

and follow the instructions you are given. Sometimes, an injury is more severe than it appears. If your child

has persistent vomiting, a worsening headache, a seizure, or is acting differently, you should take your child to

an emergency department for immediate attention.

What are the signs and symptoms of a concussion?

SIGNS OBSERVED BY PARENTS,

ATHLETIC TRAINERS, FRIENDS,

TEACHERS OR COACHES

SYMPTOMS REPORTED BY

ATHLETE

• Dazed or stunned appearance.

• Headache or “pressure” in

head.

• Confusion about assignment or

position.

• Nausea

• Forgetfulness.

• Balance problems or dizziness

• Uncertainty of game, score, or

opponent.

• Double or blurry vision

• Clumsy movements.

• Sensitivity to light or noise

• Slow response to questions.

• Feeling sluggish, hazy, foggy

or groggy

• Mood, behavior or personality

changes.

• Concentration or memory

problems

• Can’t recall events prior to or after

hit or fall.

• Confusion

• “Not feeling right” or “feeling

down”

How can a concussion affect schoolwork?

Following a concussion, many students have difficulty in school due to difficulties with short-term memory,

concentration, and organization.

In many cases after the injury, it is best to decrease the athlete’s class load early in the recovery phase. This

may include staying home from school for no more than 1 or 2 days, followed by academic adjustments (such

as a reduced class schedule), until the athlete has fully recovered. Decreasing the stress on the brain and not

allowing the athlete to push through symptoms will shorten the recovery time and ensure total resolution of

symptoms. The academic adjustments are best managed by a school concussion team. Speak with the school

guidance counselor, school nurse, or athletic trainer to help with this process.

When can an athlete return to play following a concussion?

After suffering a concussion, or if you suspect an athlete has a concussion, no athlete should EVER return to

play or practice on that same day.

Concerns over athletes returning to play too quickly led lawmakers in all 50 states and the District of Columbia

to pass laws stating that no player shall return to play the day of a concussion, and the athlete must be

cleared by an appropriate health-care professional before being allowed to return to play in either games or

practices. Many of these laws require players, parents and coaches to receive education on the dangers of

concussion in addition to recognizing the signs and symptoms of concussion. Click here to see what your

state law requires:

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/pmr/documents/concussion_t

oolkit/laws/state.htm

Once an athlete no longer has symptoms of a concussion AND is cleared by an appropriate health-care

professional to begin a return to play progression, the athlete must proceed with activity in a step-wise

fashion in a carefully controlled and monitored environment to allow the brain and body to re-adjust to

exertion. On average, the athlete will complete a new step every 24-48 hours. An example of a typical return-

to-play schedule is shown below:

Return to Play Progression:

Step 1: Back to Regular Activities

To enter into the return to play protocol the athlete should first be back to regular activities (such as school)

and has the cleared by their health-care professional to begin the return to play process. In most all cases, the

athlete should have all concussion-related academic adjustments removed prior to beginning the Return to

Play Program.

Step 2: Light Aerobic Activity

Begin with light aerobic exercise only to increase heart rate. This means about 5 to 10 minutes on an exercise

bike, brisk walking, or light jogging. No anaerobic activity such as weight lifting should be done at this stage.

Step 3: Moderate Activity

Continue with activities that increase an athlete’s heart rate while adding movement. This includes running

and skating drills.

Step 4: Non-Contact Training Activity

Add sports specific, more intense, non-contact physical activity, such as such as passing in hockey, dribbling in

basketball or soccer, high-intensity stationary biking, regular weightlifting routine.

Step 5: Practice and Full Contact

The athlete may return to practice and full contact (if appropriate for the sport) in a controlled practice setting

where the skills can be assessed by the coaches.

Step 6: Competition

The athlete may return to competition.

If symptoms occur at any step, the athlete should immediately stop activity and consult with

a qualified appropriate health-care professional before moving on to the next step.

What can I do?

 Both you and your child should learn to recognize the “Signs and Symptoms” of concussion as listed

above.

 Encourage your child to tell the medical and/or coaching staff if any of these signs and symptoms

appear after a blow to the head or body.

 Emphasize to administrators, coaches, physicians, athletic trainers, teachers and other parents your

concerns and expectations about concussion and safe play.

 Encourage your child to tell the medical and coaching staff if there is suspicion that a teammate has

suffered a concussion.

 Ask teachers to monitor any decrease in grades or changes in behavior in students that could indicate a

concussion.

 Report concussions that occurred during the school year to appropriate school staff. This will help in

monitoring injured athletes as they move to the next season’s sports.

Click here for more information about returning to school after a concussion:

http://www.cdc.gov/headsup/basics/return_to_school.html

Other Frequently Asked Questions:

Why is it so important that athletes not return to play until they have completely recovered from a

concussion?

Students that return to play too soon may worsen concussion symptoms, prolong the recovery time, and they

also risk catastrophic consequences if they suffer another head injury. These consequences are preventable if

each athlete is allowed time to recover from their concussion including completing the stepwise return-to-play

protocol. No athlete should return to sport or other at-risk activity when signs or symptoms of concussion are

present and recovery is ongoing.

Is a “CAT scan” or MRI needed to diagnose a concussion?

No! The diagnosis of a concussion is based upon the athlete’s history of the injury and an appropriate health-

care professional’s physical examination and testing. CT and MRI scans are rarely needed following a

concussion since this is a functional injury and not a structural one. However, they are helpful in identifying

life-threatening head and brain injuries such as skull fractures, bleeding or swelling.

What is the best treatment to help my child recover quickly from a concussion?

Treatment for concussion varies from one person to the next. Immediately after a concussion, the best

treatment is physical and cognitive rest. Exposure to loud noises, bright lights, computers, tablets, video

games, television and smart phones may worsen the symptoms of a concussion. You should allow your child

to rest in the days following a concussion. As the symptoms lessen, an appropriate health-care professional

may allow increased physical and cognitive activity, but this has to be monitored closely for a recurrence of

symptoms.

There are no medications to treat concussions, but an appropriate health-care professional may prescribe

medications and therapies to treat symptoms of a concussion, such as headache, dizziness, sleep changes, etc.

Some athletes may require rehabilitative therapies, such as physical, occupational, vestibular, ocular or

speech/cognitive. Others may require treatment for mood and behavior changes. All of these interventions

are done on a personalized basis.

How long do the symptoms of a concussion usually last?

For most concussions, symptoms will usually go away within 2–3 weeks after the initial injury. You should

anticipate that your child will not fully participate in sports for several weeks following a concussion. In some

cases, symptoms may last longer, sometimes several months. Since recovery differs from person to person, all

concussions should be carefully managed.

How many concussions can an athlete have before we should consider retiring from playing sports?

There is no “magic number” of concussions that determine when an athlete should give up playing sports that

put one at high risk for a concussion. The circumstances that surround each individual injury, such as how the

injury occurred as well as the number and duration of symptoms following the concussion, are very important.

These circumstances must be individually considered when assessing an athlete’s risk for potential long-term

consequences and potentially more serious brain injuries. The decision to “retire” from sports is a decision

best reached after a complete evaluation by your child’s primary care provider and consultation with an

appropriate health-care professional who specializes in treating concussions.

I’ve read recently that concussions may cause long-term brain damage in athletes, especially professional

football players. Is this a risk for high school athletes who have had a concussion?

Recently, increasing attention has been directed at CTE or Chronic Traumatic Encephalopathy. CTE is a brain

disease that results from changes in the brain. These changes can affect how a person thinks, feels, acts, and

moves. The cause of CTE has not been definitively established. Traumatic brain injuries, including

concussions, and repeated hits to the head, called sub-concussive head impacts, may contribute to CTE.

Sub-concussive head impacts are impacts to the head that do not cause a concussion. Unlike concussions,

which cause symptoms, sub-concussive head impacts do not cause symptoms. A collision while playing sports

is one way a person can get a sub-concussive head impact.

Early evidence suggested that the more years a person has repeated sub-concussive head impacts or other

brain injuries, the higher the chance they have of getting CTE. However, we have now learned that CTE does

not just occur in athletes. And, most people with head impacts or brain injuries will not get CTE. Furthermore,

CTE has been diagnosed in people who have never had any history of brain trauma.

In light of the suggestion of a correlation between head impacts and CTE, the NFHS SMAC recommends

limiting full contact during practice sessions and limiting the total number of quarters or periods played per

week in sports at high risk for head impacts, such as football and ice hockey. These recommendations and

guidelines were defined in the report from the July 2014 NFHS Concussion Summit Task Force. The guiding

principles used to develop this report were to reasonably limit the opportunity for multiple hits to the head

and to minimize concussion risk. The goal is also to maintain the integrity of the games and avoid unintended

consequences. The report can be read in its entirety in the Resources section on the Sports Medicine page of

the NFHS Website.

We cannot eliminate all of the risk of concussion from sports. However, we can take what we learn from

science to reduce the chance for injury and set policy to ensure that students with a concussion get the care

they need.

Everyone involved in high school sports plays an active role in educating others about concussion and other

serious brain injuries. Please check out the Resource section on the Sports Medicine page of the NFHS

Website for more information on how you can take an active role and get involved in keeping students safe,

healthy and active.

Some of this information has been adapted from the CDC’s “Heads Up: Concussion in High School Sports”

materials by the NFHS’s Sports Medicine Advisory Committee. Please go to

www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm for more information.

Revised and Approved April 2019

April 2016

April 2013

April 2010

DISCLAIMER – NFHS Position Statements and Guidelines

The NFHS regularly distributes position statements and guidelines to promote public awareness of certain health and safety-related issues. Such information is

neither exhaustive nor necessarily applicable to all circumstances or individuals and is no substitute for consultation with appropriate health-care professionals.

Statutes, codes or environmental conditions may be relevant. NFHS position statements or guidelines should be considered in conjunction with other pertinent

materials when taking action or planning care. The NFHS reserves the right to rescind or modify any such document at any time.