Concussion awareness and protocols transformed. ‘When in doubt, hold them out.’

September 13, 2021

By Rick Ansorge, for UCHealth

Dr. Sourav Poddar, a UCHealth sports medicine specialist, remembers the bad old days when student-athletes routinely played through injuries such as sports-related concussions.

As an aspiring soccer player, Poddar wouldn’t have considered it right to go to the sidelines unless he simply couldn’t continue to play.

child athlete tested for a sports-related concussion.
It’s imperative to quickly recognize the signs and symptoms of a sports-related concussion and ensure that the affected athlete receives appropriate treatment and rehabilitation. Source: Getty Images.

But after 22 years as a doctor for the University of Colorado Buffaloes, whom he supervises as medical director, Poddar has witnessed what he calls a “sea change” in the way concussion is diagnosed and managed.

“Today the mantra is ‘when in doubt, hold them out,’” Poddar said. “That’s a big change. A lot of that is due to awareness, which I think is great.”

Concussion awareness has increased among medical professionals, athletic trainers, coaches, student-athletes and parents that every so-called rung bell is an alarm bell, and that “playing through” is no longer an option. Today, it’s imperative to quickly recognize the signs and symptoms of a sports-related concussion and ensure that the affected athlete receives appropriate treatment and rehabilitation.

UCHealth has an extensive network of sports medicine doctors and concussion clinics that offer individualized healing protocols aimed at speeding recovery and getting student-athletes and other patients back to their normal lives. These include the UCHealth Concussion Multidisciplinary Clinic at the Anschutz Medical Campus in Aurora and the UCHealth Concussion Assessment Clinic at Memorial Hospital in Colorado Springs.

How common are sports-related concussions?

Despite the widespread adoption of game-rule changes and improved sports equipment to reduce the risk of concussion, student-athletes in contact sports still have a 10-20% risk of concussion each playing season. These include sports such as football, hockey, rugby, soccer, lacrosse, basketball, wrestling, baseball and even cheerleading.

Among high school football players alone, an estimated 250,000 concussions occur each year.

Concussions can affect everyone from infants to senior citizens. Overall, most concussions are caused by non-sports-related accidents, falls, and physical assaults. Sports-related concussions are more visible because they often occur at well-attended events and affect athletes who are seemingly in tip-top condition.

What’s not generally known is that adolescents have a higher risk of concussion than any other age group. That’s because their brains are still developing and their neck muscles are relatively weak compared to young and older adults.

Dr. Sourav Poddar, who discusses sports-related concussions in this article.
Dr. Sourav Poddar

That makes them more vulnerable to blows to the head that make the brain bounce, twist, and whiplash against the skull, which injures brain tissue and temporarily affects brain function.

What are the signs and symptoms of a sports-related concussion?

Headache is the most common symptom of concussion. Other symptoms include:

  • Vomiting or nausea
  • Sensitivity to light or noise
  • Trouble thinking normally
  • Memory problems
  • Trouble walking
  • Confusion
  • Dizziness
  • Vision problems
  • Fatigue
  • Mood changes
  • Changes in sleep patterns

After an injury, symptoms typically appear within several minutes. But it’s not uncommon for symptoms to develop several hours later or change over the course of several days. New symptoms also can appear when the brain is stressed by school or work activities.

“Every concussion is different,” Poddar said. “Some concussions affect the memory domains in your brain. Other concussions affect the vestibular or balance domains. Still other concussions affect the ocular or eye-movement domains, or affect anxiety and mood. Many concussions affect multiple domains.”

When is a sports-related or other concussion a medical emergency?

If a child or adult experiences any of the following symptoms in the hours or days after the head injury, get them to the hospital or call 911:

  • Severe headache or a headache that continues to get worse over time
  • Seizures or convulsions
  • Loss of consciousness (greater than 1 minute)
  • Severe dizziness, loss of balance or problems with walking
  • Repeated vomiting (more than once)
  • Increasing confusion, such as difficulty recognizing people or places
  • Clear, watery discharge from the nose or ears
  • Bloody discharge from the ears
  • Numbness, weakness or tingling in arms or legs
  • Unusual, bizarre or irritable behavior
  • Slurred speech
  • Pupils that are bigger than normal or unequal in size
  • Extreme drowsiness, difficulty waking from sleep, or fainting

What should be done immediately to manage a suspected sports-related concussion?

Even if symptoms are seemingly mild, it’s imperative that the athlete sit out the game or practice.

“If you say you feel OK, you might still be a little bit dazed,” Poddar said. “That’s the time when you should come over to talk to your team trainer or your team doctor to get assessed.”

The National Federation of State High School Associations recommends the following steps for returning to sport after an athlete has had a concussion:

Step 1: Light aerobic exercise- 5 to 10 minutes on an exercise bike or light jog; no weight lifting, resistance training or any other exercises.

Step 2: Moderate aerobic exercise- 15 to 20 minutes of running at moderate intensity in the gym or on the field without equipment.

Step 3: Non-contact training drills in full uniform. May begin weightlifting, resistance training and other exercises.

Step 4: Full contact practice or training.

Step 5: Full gameplay

Staying in the game or practice increases the risk of another concussion, which not only prolongs recovery time but also increases the risk of serious and even lifelong complications. In rare instances, a severe concussion can be fatal.

Once you’ve had a concussion, you’re three to five times more likely to experience another one.

How is a sports-related concussion diagnosed?

On the sidelines, Poddar and his colleagues rely on a comprehensive assessment of the athlete’s symptoms.

If they know the athlete, they can tell if he or she is behaving or thinking differently than usual. If they don’t, they can ask trainers, coaches and other team members if the athlete is behaving or thinking abnormally.

They also use an assessment tool called the SCAT5, which includes a battery of 22 symptoms, each of which are rated on a scale of zero to six.

The SCAT5 scoring summary includes the following sections:

  • Red flags.
  • Memory assessment – Maddocks Questions.
  • Glasgow Coma Scale (GCS) examination.
  • Cervical spine assessment.
  • Symptom evaluation.
  • Cognitive screening.
  • Neurological screening.
  • Balance examination.
  • Delayed recall.

SCAT5, which is available online for free, is intended for use by medical professionals. A simplified version, the Concussion Recognition Tool (CRT5) is intended for use by the lay public

If a concussion is suspected based on a lay person’s CRT5 assessment, a medical doctor or nurse practitioner should conduct a medical assessment.

How is a sports-related concussion treated?

Traditionally, student-athletes with a suspected concussion were sent home to rest in a dark room and stay there until they felt better.

“Now we know that’s probably not the best thing,” Poddar said.

Rest is still important, especially during the first 48-72 hours. After that initial period, however, medical experts now recommend that the athlete engage in what’s called “sub-threshold” exercise.

“It’s not a workout,” Poddar said. “It may be just getting on an exercise bike with the resistance turned down, getting your legs loose, and trying to figure out how much you can do without making your symptoms worse.”

Such gentle exercise releases brain chemicals that can speed healing, he explained.

As part of a medically supervised concussion protocol, the athlete can gradually increase the intensity and duration on an exercise bike or treadmill in a subthreshold manner. Early interventions also can include targeted rehab exercises aimed at improving balance and hand-eye coordination.

Studies show that sub-threshold physical exercise – combined with non-stimulating social interaction or “sub-threshold” cognitive exercise – is beneficial. “During recovery, it’s good to add in some of the things that make people feel normal and not isolated,” Poddar said.

How long does it take to recover from a sports-related concussion?

“With a standard concussion, you’re typically back within two weeks,” Poddar said.

But recovery time is highly variable and depends on many factors. These include the number of concussions the athlete has experienced in his or her lifetime, and the presence of other health conditions such as migraine, depression, and anxiety.

Most concussion symptoms resolve within 14-21 days. But in cases where the concussion is undiagnosed, unrecognized or poorly treated, a full recovery can extend beyond the typical two weeks to months or even longer.

How soon can a student-athlete return to sports after a concussion?

“It’s a graded return,” Poddar said. “If you’re a hockey player, it’s not that you become asymptomatic one day and the next day you’re back on the ice checking people.”

If tolerated, the athlete can start engaging in more vigorous cardiovascular exercises such as jogging or running as well as strength training exercises such as weight lifting.

Football players are encouraged to ease back into the game by throwing and catching balls to improve their hand-eye coordination and engaging in non-contact practice. “You’re not hitting people but you’re getting out there and having to react to other players,” Poddar said.

“Finally, there’s contact practice and then gameplay,” he said.

A similar strategy applies to resuming scholastic activities.

“Obviously, you may not want to take your physics final on the day you get back from a concussion,” Poddar said.

But it’s important for the athlete to return to school, full-time if possible, and see how much class time he or she can tolerate.  Return to class should precede a return to full gameplay.

At first, it might be only 10 minutes at a time in class before the athlete has to rest in an agreed-upon space, such as a nurse’s office. What’s important is to gradually increase the amount of class time and interactions with teachers and other students.

“It starts getting the individual back into their routines a little faster, which can be helpful in healing,” Poddar said.