Concussion Severity & Return to Play (RTP) Guidelines
Myth:All team doctors and certified athletic trainers (ATs) use the same concussion grading scale in determining concussion severity.
Because of the lack of scientific studies and the amount of clinical judgment involved in the management of concussions, there is no consensus in either
The promulgation during the 1980's and 1990's of no less than sixteen different grading systems for concussions so confused and frustrated sports medicine professionals that many ended up not using any of the grading scales for evaluations purposes
The strong trend in the 2000s, as reflected in the most recent international consensus statement on concussions, is not to assign any concussion a "grade" but to manage and treat concussions as a matter of clinical judgment on an individualized basis after considering clinical
Myth: All team doctors and certified athletic trainers (ATs) follow the same guidelines in determining when an athlete can safely return to play.
Fact: The all-important decision of when to allow an athlete to return to play continues to be marked by controversy, and no one approach has gained universal approval. Many programs do not follow any set of return-to-play guidelines, and there are even some clinicians who believe that current RTP guidelines are too conservative (although this group is, thankfully, a ever-shrinking minority). The more is known about concussions, especially among adolescents (new research suggesting that, on average, neurocognitive impairment may persist for high school athletes from 10 to 21 days after concussion, as compared to the 5- to 7-day recovery documented for college athletes; [12] concussed high school athletes take twice as long to recover (10 to 14 days) than college or professional athletes (3 to 7 days), [16-18] and preadolescent children may take even longer to recover [18]. Such studies suggest that, if anything, guidelines are not conservative enough, with an increasing number of concussion experts, including MomsTEAM's sports concussion neuropsychologist, Rosemarie Scolaro Moser, calling for an athlete to wait a minimum of three weeks before returning to sports after a concussion.
As recently as 2000, nearly one-third (30%) of all high school and collegiate football players sustaining concussions were allowed to return to competition on the same day of injury, with the remaining 70% averaged 4 days of rest before return-to-play (RTP). A 2009 study (6) of high school athletes during the 2005-2008 period found that at least 40.5% and 15.0% of concussed athletes returned to play prematurely under the old American Academy of Neurology (AAN) and more recent Vienna/Prague/Zurich return-to-play guidelines, respectively. In football, 15.8% of athletes sustaining a concussion that resulted in loss-of-consciousness returned to play in 1 day or less, with males (12.6%) more likely than females (5.9%) to retun to 1-2 days after sustaining a so-called "grade II" concussion under the old AAN guidelines.
Unfortunately, such liberal departures from RTP guidelines - with the most recent international consensus statement [2] calling for no same day return to play for athletes under the age of 18 and no return to play until an athlete is symptom free for at least 7 days and has completed a step-wise return to play exercise protocol - may end up putting athletes at increased risk of a second concussion, which, in athletes under age 18, could have catastrophic consequences (e.g. second impact syndrome).
Recent statistics on return-to-play compliance, however, paint a better picture, suggesting that far fewer athletes are being allowed to return to play on the same day as their injury. A study published in December 2010 of concussions in nine high school sports during the 2008-2009 school year, reported that only 3.3% of athletes were returned to play on the same day as their injury. [5]
The number of athletes allowed to return to play on the day of injury is likely to drop even further in the future as a result of the passage of laws in every state which prohibit same day return to play.
Myth: It is safe for a player to return to the same game or practice if he suffers only a brief LOC.
Fact: The 2012 Zurich consensus statement on concussion in sport [2] flatly states that a player who suffers ANY signs or symptoms of concussion should NOT be allowed to return to the current game or practice no matter how quickly symptoms may clear.
Two 2003 studies suggest that a 7-day waiting period may minimize the risk of another concussion. Not only does the evidence show that athletes take, on average, 7 days to fully recover after a concussion, but same-season repeat injuries typically take place 7 to 10 days after the first, which supports the idea that the brain may be more vulnerable to injury during the first 7 days after injury. [2]
Again, it is important to note that, by law in all 50 states and the District of Columbia, and by rule at the high school level via the National Federation of High School Associations, athletes are now prohibited from same day return to play if a concussion is suspected, with no return to play without written clearance from a medical professional with specialized knowledge of and expertise in concussion evaluation and management.
Myth: It is safe for a player to return to the same game or practice if, after suffering a concussion, he is symptom free within 15 or 20 minutes, both at rest and with exertion.
Fact:The 2012 Zurich consensus statement on concussion in sport [2] states that any player under age 18 who suffers ANY signs or symptoms of concussion should NOT be allowed to return to the current game or practice no matter how quickly symptoms may clear.
Recent studies of high school and collegiate athletes emphasize the importance of making sure that an athlete is symptom free before being allowed to return on the same day because, even if the athlete is symptom free within 15 or 20 minutes, he may still have delayed symptoms or impairment of cognitive functioning [2](citing studies).
A 2004 study in the American Journal of Sports Medicine found significant memory deficits 36 hours post-injury in athletes who were symptom-free within 15 minutes of a mild concussion. A 2003 study in the Journal of the American Medical Association found that nearly three times as many concussed athletes who were allowed to return the day of injury experienced delayed onset of symptoms 3 hours post-injury as athletes who sat out the rest of the game or practice.
Again, this more conservative approach to sport-related concussions - one barring an athlete with suspected concussion from returning to play without written approval from a health care professional trained in the evaluation and management of concussion - has been adopted by law in 48 states and the District of Columbia since May 2009.
Concussion Management in Youth Sports
Myth: Concussions suffered by athletes under the age of 18 are managed the same way as concussions suffered by adult athletes.
Fact: The Zurich consensus statement on concussion in sport [2] strongly recommends that concussions in athletes under age 18 be managed more conservatively than concussions in college-age and professional athletes, even if the same medical resources are available, and an elite athlete is the patient. "Because of the different physiological response and longer recovery after concussion and specific risks (eg, diffuse cerebral swelling) related to head impact during childhood and adolescence, a more conservative RTP is recommended," says the statement. It also says it is "appropriate to extend the amount of time of asymptomatic rest and/or length of the graded exertion in children and adolescents."
Such a conservative approach when making return-to-play decisions among adolescent athletes is consistent with a 2012 study [12] that found that high school athletes took significantly longer to recover neurocogntive function after concussion than college athletes.
This more conservative approach is also embodied in the laws enacted since May 2009 in 48 states and D.C. prohibiting same day return to play and requiring medical clearance before an athlete is allowed to return to play. In July 2014, California became the first state in the country to mandate completion of a minimum 7-day graduated return to play protocol before a student-athlete is allowed to return to play. Other states are likely to follow.
Myth: Youth athletes recover from concussions at the same rate as older athletes.
Fact: Studies suggest that there are age-related differences between high school and college athletes in terms of recovery. [12,16,17] High school players are more susceptible to post-concussion syndrome and serious injury than college or professional players, their developing brains take longer to heal, and they are more prone to subsequent concussions. Studies have also shown that high school athletes who suffered concussions experienced more prolonged problems with memory than college athletes and performed significantly worse on memory tests 7 days post-injury compared to college athletes.[12] As a result, the Zurich consensus statement recommends extending the time of asymptomatic rest and/or the length of the step-wise exercise program younger athletes must complete before returning to play.
Myth: Girls suffer concussions at the same rate as boys.
Fact: According to a 2007 study, girls appear more susceptible to concussions in sports like soccer and basketball than boys. Girls playing high school soccer suffer concussions at twice the rate of boys soccer players. Female concussion rates in high school basketball are 1.4 times higher than for boys. While the role of gender in concussion rates and return to play has been an area of active research in recent years, the results are mixed.
The reasons concussion rates are consistently higher for girls than boys in the same sport are unclear, but experts speculate that they may be due to anatomical (eg. less developed neck muscles, with one study showing that female athletes have 49% less muscle strength and 30% less muscle girth than male athletes), biological (it has been suggested that the female sex hormone, estrogen, may make females more susceptible to concussive brain injury), and/or cultural reasons (coaches and parents may be more sensitive to injury to the female head, girls may be more honest than boys and self-report at a higher rate than boys, and male athletes are often taught that they should "tough it out" and play through injury, and report that nothing bothers them even when they are injured).
Some studies have revealed differences in cognitive function (the functions of the brain that involve thinking, concentrating, learning and reasoning) between male and female athletes. These differences are true both before and after injury. In one study, collegiate women's soccer players who sustained a concussion had slower reaction times than male collegiate soccer players who sustained a concussion. Other studies have shown differences in memory between male and female athletes.
The jury is still out on whether gender is a risk factor for concussion injury and/or influence injury severity. There is, as of yet, no unanimous agreement that the current published research evidence is conclusive enough to warrant gender being formally recognized as a modifying factor in concussion evaluation and management.
Studies have yielded conflicting results: a 2010 study reported, contrary to earlier studies, no gender differences in concussion outcomes or severity, with high school girls and boys who suffer concussions in sports reporting the same number of symptoms, and taking the same time for their symptoms to clear and to return to play. The one difference: girls report symptoms that are more subtle and easily missed or could be attributed to causes other than concussion than those boys. A 2012 study [13] of boy and girl high school soccer players, however, found no gender-specific difference in response to acute concussion, either from a symptom standpoint or in scores on neurocognitive (e.g. ImPACT) tests. On the other hand, a different 2012 study [12] found that female athletes - both college and high school - performed worse than male athletes on tests of visual memory and reported more postinjury symptoms after concussion.
Myth: Concussions among female athletes aren't taken as seriously as those suffered by boys.
Fact: As recently as 2007, MomsTeam concussion expert emeritus, Dr. Robert Cantu, told the New York Times that, "Generally speaking, the medical profession does not do a very good job in recognizing that female athletes sustain concussions at an equal or even higher rate as males," asserting that concussions among girls were "flying under the radar," and that looking for concussions in women was "not pursued with the same diligence, and it's setting girls up for a worse result."
A 2010 study, however, suggests a changing landscape. It found high school girls and boys who suffer concussions in sports reporting the same number of symptoms, and taking the same time for their symptoms to clear and to return to play. "The fact that symptom duration and RTP time-lines were similar ... showed that there was not a drastic difference between the way girls and boys are treated with respect to care, follow-up and return to play," said Susan A. Saliba, PhD, PT, ATC, an Assistant Professor at the Curry School of Education; Physical Medicine and Rehabilitation at the University of Virginia, and one of the study's co-authors. "We were happy [to find] that girls did not seem to be more adversely affected by concussion symptoms than boys."
Myth: Girls recover from concussions at the same rate as boys.
Fact: The jury is still out on this one. A 2007 study in the Journal of Athletic Training found that girls took much longer than boys for symptoms to resolve and to return to play, although the reasons for delayed recovery remain unclear, but a 2011 study reported in the same journal found that girls took about the same time as boys for their symptoms to clear and to return to play.
Myth: Most athletes know when they have suffered a concussion and report them to their coach, athletic trainer or team doctor.
Fact: Many athletes do not understand precisely when they have suffered a concussion (many still think that it requires a loss of consciousness), and wouldn't tell the coach even if they knew they had sustained one. The macho culture of sports, particularly in such aggressive contact and collision sports as football, hockey, and boys lacrosse, puts athletes under significant pressure to "shake off" a concussion or "take it like a man" - pressure that coaches and parents often exacerbate, either directly or indirectly or subtly, in their desire for team and individual success - which results in a drastic and chronic underreporting of concussions and can lead to serious harm (e.g. second impact syndrome). A oft-cited 2004 study in the Clinical Journal of Sports Medicine [3] that 53% of concussed high school athletes are suspected of not reporting their injuries to medical personnel. A 2013 study reported that as many as 40% of concussions suffered by high school athletes go unreported, with just 13% reporting being "dinged" or having their "bell rung." [14] There is also a tendency of young players to imitate NFL players (or, because of the 2014 FIFA World Cup, in professional soccer players) , many of whom are afraid to report a concussion because it might affect their next contract.
Athletes need to understand the signs and symptoms of a concussion as well as the range of negative consequences of not reporting a concussion, from predisposition to future concussions to long-term cognitive (e.g. memory) and emotional difficulties (e.g. depression), to development of a neurodegenerative condition called chronic traumatic encephalopathy (CTE) that mimicks early Alzheimer's, to catastrophic injury (e.g. second impact syndrome).
Myth: Only athletes that suffer concussions run the risk of suffering adverse long-term health consequences.
Fact: Recent studies establish that not only can concussions lead to postconcussion syndrome and increased risk of long-term cognitive, emotional, and behavioral problems, and even to neurodegenerative diseases such as chronic traumatic encephalopathy, but a growing body of research suggests that repeated subconcussive blows may lead to the same problems. [7,8,9]
Safety Equipment
Myth: Mouth guards prevent concussions.
Fact: There is no "good clinical evidence" that mouthguards will prevent concussion. [2,4,7] A properly fitted mouth guard, regardless of type (boil-and-bite or custom-made), should nevertheless be worn because of its value in protecting the teeth and preventing fractures and avulsions that could require many years of expensive dental care. [7]
Myth: All football helmets reduce the risk of concussion.
Fact: While helmets have been shown to protect against skull fracture, severe traumatic brain injury (TBI), and death, and while biomechanical studies have shown that the use of head gear and helmets can reduce impact forces to the brain and provide more protection against some of the forces that may lead to concussion, there is very little evidence that a particular brand of helmet reduces the incidence of concussion [2,7].
While a 2014 study [19] by some of the nation's top concussion researchers found that the design of football helmets can effect concussion risk, providing what the authors said was good clinical evidence that helmet design can lower the risk of concussion, not in a laboratory, but in games and practices, the study left unanswered the practical question faced by football parents, coaches, and administrators as to whether a difference in concussion risk reduction exists between new helmet models incorporating such new design features, and does nothing to change the prevailing view that no helmet has yet been designed which can prevent all concussions. a point conceded by the Virginia Tech researchers responsible for the STAR football helmet ratings: "Any player can sustain a head injury even with the very best protection. A specific person's risk of concussion may vary as a result of a number of factors" having nothing to do with the helmets, including genetic differences (some athletes may be genetically pre-disposed to concussion), age, health history (e.g. history of migraines, depression or other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, sleep disorders, and/or previous history of concussion), impact factors (e.g. neck muscle strength/weight), style of play, etc." Indeed, another 2014 study [15,20] reported that the risk of sustaining a concussion in high school football is not affected by the brand, age of the helmet, or recondition status.
Myth: Brand-new football helmets provide more protection against concussion than older helmets.
Fact: The risk of sustaining a concussion in high school football is not affected by the brand or age of the helmet or by the type of mouth guard worn, say researchers from the University of Wisconsin. [15,20]
Myth: Soccer headgear is effective in protecting athletes against concussions.
Fact: Another issue on which the jury is out. While a 2005 British study sponsored by the sports medicine committee of FIFA, soccer's world governing body, found that headgear provided no measurable benefit in head-to-ball impacts, it concluded that headgear did provide measurable benefit in head-to-head impacts. A 2007 study by researchers at Canada's McGill University found that teenage soccer players wearing protective headgear suffered nearly half as many concussions as those who played without helmets. The study also seemed to show that wearing headgear did not encourage soccer players to play more aggressively, as some had feared. A 2010 Clinical Report from the American Academy of Pediatrics' Council on Sports Medicine and Fitness [4] finds no evidence to support a finding that soccer headgear reduces the risk of concussion.
Reviewing this research in his 2011 book, Kids, Sports, and Concussion, MomsTeam concussion expert and Director of the Sports Concussion Center at Children's Hospital Boston, William P. Meehan III, M.D., concludes that, "[u]ntil further medical studies are conducted, no definitive conclusions regarding the use of soccer headbands to reduce the risk of concussion can be reached."
For the most comprehensive, up-to-date concussion information on the Internet, click here.
1. Broglio, et. al, Head Impacts During High School Football: A Biomechanical Assessment, J Athl Tr. 2009; 44(4): 342-349.
2. P. McCory, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47;250-258.
3. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players - Implications for prevention. Clin J Sport Med 2004;14:13-17.
4. Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics. 2010;126(3):597-615.
5. Meehan W, d'Hemecourt P, Comstock D, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am J Sports Med. 2010;38(12):2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).
6. Meehan W, d'Hemecourt P, Comstock D, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am J Sports Med. 2010;38(12):2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).
7. Daneshvar DH, Baugh CM, et. al. Helmets and Mouth Guards: The Role of Personal Equipment in Preventing Sports-Related Concussion. Clin Sports Med 2011;30:145-163.
8. McKee AC, Gavett BE, Stern RA, et al. TDP-43 proteinopathy and motor neuron disease in chronic traumatic encephalopathy. J Neuropathol Exp Neurol 2010;69(9):918-29.
9. McKee AC, Cantu RC, Nowinski CJ. et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp. Neurol 2009:68(7):709-35.
10. Daniel R, Rowson S, Duma S. Head Impact Exposure in Youth Football. Annals of Biomed Eng 2012: DOI:10.1007/s10439-012-0530-7 (accessed February 15, 2012).
11. Mickalide AD, Hansen LM. Coaching Our Kids to Fewer Injuries: A Report on Youth Sports Safety. Washington, DC: Safe Kids Worldwide, April 2012
12. Covassin T, Elbin R, Harris W, Parker T, Kontos A. The Role of Age and Sex in Symptoms, Neurocognitive Performance, and Postural Stability in Athletes After Concussion. Am J Sports Med 2012;20(10); published on April 26, 2012 at doi:10.117703654651244454.
13. Zuckerman SL, Solomon GS, Forbes J, Haase R, Sills AK, Lovell MR. Response to acute concussion injury in soccer players: is gender a modifying factor. J Neurosurg: Pediatrics 2012: DOI: 10.3171/2012.8.PEDS12139 (published ahead of print October 2, 2012)(accessed October 13, 2012).
14. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW. Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study. J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)
15. McGuine T, Brooks A, Hetzel S, Rasmussen J, McCrea M. "The Association of the Type of Football Helmet and Mouth Guard With the Incidence of Sport-Related Concussion in High School Football Players." Presentation Paper AOSSM, July 13, 2013.
16. Field M, Collins MW, Lovell MR, et al. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr. 2003;142:546-553.
17. Grady MF. Concussion in the adolescent athlete. Curr Probl Pediatr Adolesc Health Care. 2010;40:154-69.
18. Davis GA, Purcell LK. The evaluation and management of acute concussion in young children. Br J Sports Med. 2014;48:98-101. doi:10.1136/bjsports-2012-092132.
19. Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery 2006;58:275-286
20. McGuine TA, Hetzel S, McCrea M, Brooks AM. Protective Equipment and Player Characteristics Associated With the Incidence of Sport-Related Concussion in High School Football Players. Am J Sports Med. 2014;20(10)(published online ahead of print, July 24, 2014 as doi:10.1177/036354651541926.
Additional source: Meehan WP III. Kids, Sports, and Concussion (Praeger 2011).
First posted in 2001; most recently updated December 11, 2015.
Senior Health and Safety Editor Lindsey Barton Straus contributed to the preparation of the original version of this article and to its frequent updates over the past 15 years.
