Concussions an overview of the injury and the return to activity process
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Concussions: An Overview of the Injury and the Return to Activity Process. Rusty McKune, ATC Sports Medicine Program Coordinator The Nebraska Medical Center. Concussion…. The term and therefore, definition, diagnosis, and treatment of concussion is very dynamic.

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Concussions:An Overview of the Injury and the Return to Activity Process

Rusty McKune, ATC

Sports Medicine Program Coordinator

The Nebraska Medical Center


  • The term and therefore, definition, diagnosis, and treatment of concussion is very dynamic.

    • Consensus Statement on Concussion in Sport: the 4rdInternational Conference on Concussion in Sport (Zurich, 2012)

  • Concussion is a complicated injury that can present in a variety of ways.

  • Concussion- Defined

    • A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. (Zurich, 2012)

      - Concussion may be caused by a direct blow to the head, face, or neck or elsewhere on the body with an “impulsive” force transmitted to the head;

      - Typically results in the rapid onset of short lived impairment of neurological functioning that resolves spontaneously;

      - Results in a graded set of clinical syndromes that may or may not involve the loss of consciousness;

      - No abnormality on standard structural neuroimaging studies.

    Characteristics of Concussions

    We now know that….

    • “dings,” “bell-ringers” are concussions

    • Concussions do not have to involve LOC

    • Functional Disturbance (Software), Not a Structural Injury (Hardware);

    • Young athletes are at increased risk for serious problems

      (CDC 2012)

      • Less developed shoulder/cervical spine musculature

      • Poor technique

      • Brain is not as developed and less able to withstand the insult associated with a concussive injury.




    What Does a Concussion Look Like?

    Common Symptoms of Concussion

    • Headache

    • Feeling Slowed Down

    • Difficulty Concentrating

    • Dizziness

    • Fogginess

    • Fatigue

    • Blurred Vision

    • Sensitivity to Light/Noise

    • Memory Problems

    • Balance Problems

    “What they tell us.”

    Common Signs of Concussion

    • Vacant Stare

    • Slow to Answer Questions or Follow Instructions

    • Easily Distracted

    • Disoriented; can’t focus attention

    • Disoriented; unaware of time, date, and place

    • Slurred or incoherent speech

    • Sensitivity to light/noise

    • Memory Deficits (can’t remember events prior to or after the injury)

    • Gross Incoordination

    • Emotions out of proportion to the situation

    • Loss of Consciousness

    • Seizures

    “What we see/observe”

    Beyond the Field of Play

    • Personal/Home

      • Reduced Play/Activity

      • Difficulty completing chores

      • Depression

      • Irritability:

        • Parents

        • Siblings

        • Boyfriend/Girlfriend

    • Academic/School

      • Concentration/Focus

      • Remembering Assignments

      • Tolerance of Environment

      • Fatigue

      • Drop in Grades, Attendance

    Concussion Management

    How Do We Manage Concussions?

    • Best Treatment is Prevention

      • Is this possible?

    • So we do out best to:

      • Educate

      • Recognize, Remove, and Refer

      • Diagnose

      • Manage

      • Prevent further Injury

    How Do We Manage a Concussion and Prevent Further Injury?

    Recognition relies on Education

    Preventing 2nd injury relies on Management

    Diagnosis relies on Recognition

    Management relies on Diagnosis

    The concussion awareness act

    Goals and Objectives of the Concussion Awareness Act

    • Consistent means to identify and manage concussions to ensure the safety of those involved in youth sports.

    • Contains the three tenets of model legislation

      • Education- Coaches, Parents and Student Athletes;

      • Removal from play if a concussion is reasonably suspected;

      • Clearance by a Licensed Health Care Provider.

    Provisions of LB 260

    • Who is does the bill apply to?

      • Sec. 4- Approved or accredited public, private, denominational or parochial schools (does not include higher education/college and university);

      • Sec. 5- Athletes 19 years of age or younger that participate in organized sports (“any city, village, business or nonprofit that organizes sports, charges a fee or is sponsored by a business or nonprofit organization”).

    Provisions of LB 260- EDUCATION

    • Coaches

      • Training approved by the Chief Medical Officer must be made available to all Coaches


    • Parents and Student-Athletes and Athletes/Participants

      • Requires that information be provided on an annual basis prior to the start of practice or competition

    Provisions of LB 260- REMOVAL FROM PLAY

    • Any student-athlete or athlete shall be removed from play when they are reasonably suspected of having a concussion by a coach or licensed health care professional ( for schools, this individual must be professionally affiliated with or contracted by the school).

    • Shall not be allowed to return to play until they are cleared by a licensed health care professional.

    • Parents or Guardian must be notified of the date and approximate time of the injury and the signs and symptoms that were observed, as well as any actions taken to treat.

    Provisions of LB 260- RETURN TO PLAY

    • A student-athlete or athlete may be allowed to return to play when:

      • They have been evaluated by a licensed health care professional;

      • They have received written clearance from the licensed health care professional;

      • They have submitted the written and signed clearance to resume participation in athletic activities accompanied by written permission to resume participation from the student’s parent or guardian.

    Thoughts on Return to Play

    • General Consensus that, beyond the limits of Concussion Awareness Act, return to play should not occur until:

      • The athlete is asymptomatic at rest AND exertion;

      • The athlete has returned to their baseline scores on any neurocognitive and/or balance examinations;

      • The athlete has completed a graduated return to play progression.

    Zurich, 2008


    • At this age, not all students are athletes but



    • We can’t just focus on athletics we need to include academics.

    Return to Activity

    Returning to Activity

    A return to activity plan is composed of two parts and should be considered a medical decision with input from all members of a schools concussion management team.

    • Return to Academics- a gradual return to school and

      academic requirements implemented by the teaching staff.

    • Return to Play- a gradual return to sports implemented by

      the athletic staff.

    Returning to Activity

    Return to Activity

    Return to Learn

    Step 1- Home- Relative Rest

    Step 2- Home- Light Mental


    Step 3 School- Part Time

    Step 4 School Part Time

    Step 5 School Full Time

    Step 6 School Full Time

    Return to Play

    Step 1- No physical activity

    while there are


    Step 2- Light Aerobic Activity

    Step 3- Sport-specific exercise

    Step 4- Non-Contact Training


    Step 5- Full Contact Practice

    Step 6- Return to Play

    Adapted from Oregon Concussion and Management Program and Slocum Sports Concussion Program

    Academic Accommodations for Students

    • Excused Absence from Class

    • Rest Period During the School Day

    • Extension of Assignment Deadlines

    • Postponed or Staggered Exams

    • Excuse from Specific Tests and Assignments.

    • Extended Testing Time

    • Accommodation for Sensitivity to Light, Noise or Both

    • Excuse from Team Sport Practice and Gym Activities

    • Smaller, Quieter Exam Rooms to Reduce Stimulation and Distraction

    • Preferential Seating

    Managing a Concussion at Home

    • Rest is a key component to the healing process of the brain.

    • Each concussion is different and will respond differently.

    • Must involve both physical and cognitive rest.

    • Means both sports and school may be affected.

    • Will need to communicate with AD’s, Coaches AND Teachers.

    What is Rest?



    Limited concentration

    Modify/delay homework

    No prolonged classes and be aware of the class environment

    Shorten/modify days

    No Texting, e-mails or computers/video games.

    • No sports

    • No exercise

    • No weightlifting

    • ADL’s?


    What to do if a Concussion Occurs

    CDC Guidelines and the Concussion Awareness Act:

    • Remove from Play- do not allow them to return that day.

    • Ensure that athlete is evaluated by a health care professional experienced in evaluating concussions.

    • Inform Parents or Guardians

    • Keep out of play until symptom free and cleared by a licensed health care provider experienced in managing concussions

    How Can we Prevent Concussions and/or Limit the Effects of Concussions?


    Coaches, Parents, Athletes, Officials

    Concussion Recognition and Management


    Policies and Guidelines Regarding Concussions

    Safety Comes First



    Never “Play Through” a Concussion


    NE High School Lacrosse Concussion Awareness

    Closing Thoughts…


      • Concussions don’t just happen in sports



      • And in youth who are also students…ENDS WITH EDUCATION.



    Rusty McKune, ATC

    Work Phone: 402- 552-3522



    • Consensus Statement on Concussion in Sport, 4rd International Concussion in Sport, Zurich, November 2012.

    • Nebraska Brain Injury Resource Network- “Bridging the Gap From Concussion to Classroom.”

    • Nebraska Legislative Bill 260- The Concussion Awareness Act

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