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GUIDELINE 2i
Concussion or Mild
Traumatic Brain Injury
(mTBI) in the Athlete
account for a significant percentage
million concussions occur from of injuries in men’s and women’s
participation in sports- and basketball, women’s lacrosse, and
recreation-related activities every other sports traditionally men’s basketball 0.6, accounting
considered “noncontact.”
injuries are often difficult to detect, the injuries for these sports as
with athletes often underreporting The incidence in helmeted versus reported by the NCAA Injury
their injury, minimizing their nonhelmeted sports is also similar. Surveillance Program by the
importance or not recognizing that In the years 2004 to 2009, the rate Datalys Center.
an injury has occurred. At the of concussion during games per
Assessment and management of
college level, these injuries are
concussive injuries, and return-to-
more common in certain sports,
men’s ice hockey 2.4, for women's play decisions remain some of the
such as football, ice hockey, men’s
ice hockey 2.2, for women's soccer most difficult responsibilities
and women’s soccer, and men’s
facing the sports medicine team.
lacrosse. However, they also
There are potentially serious
complications of multiple or severe
concussions, including second
impact syndrome, postconcussive
syndrome, or post-traumatic
encephalopathy. Though there is
some controversy as to the
existence of second impact
syndrome, in which a second
impact with potentially
catastrophic consequences occurs
before the full recovery after a first
insult, the risks include severe
cognitive compromise and death.
Other associated injuries that can
occur in the setting of concussion
include seizures, cervical spine
injuries, skull fractures and/or
intracranial bleed. Due to the
serious nature of mild traumatic
brain injury, and these serious
52 potential complications, it is
imperative that the health care injuries of skull fracture, noted. These sideline tests should
professionals taking care of intracranial bleeding and seizures, be performed and repeated as
athletes are able to recognize, when there is concern for structural necessary, but do not take the place
evaluate and treat these injuries in abnormalities or when the of other comprehensive
a complete and progressive symptoms of an athlete persist or neuropsychological tests.
deteriorate.
Executive Committee adopted a Once an injury occurs and an
Concussion is associated with initial assessment has been made, it
policy that requires NCAA
clinical scenarios that often clear is important to determine an initial
institutions to have a concussion
spontaneously, and may or may not plan of action, which includes
management plan on file. (See
be associated with loss of deciding on whether additional
information box on page 55.)
consciousness (LOC). referral to a physician and/or
Concussion or mild traumatic brain emergency department should take
The sideline evaluation of the
injury (mTBI) has been defined as place, and determining the follow-
brain-injured athlete should include
“a complex pathophysiological up care. The medical staff should
an assessment of airway, breathing
process affecting the brain, induced also determine whether additional
and circulation (ABCs), followed
by traumatic biomechanical observation or hospital admission
by an assessment of the cervical
forces.” Although concussion most should be considered.
spine and skull for associated
commonly occurs after a direct
injury. The sideline evaluation Follow-up care and instructions
blow to the head, it can occur after
should also include a neurological should be given to the athlete, and
a blow elsewhere that is transmitted
and mental status examination and ensuring that they are not left alone
to the head. Concussions can be
some form of brief neurocognitive for an initial period of time should
defined by the clinical features,
testing to assess memory function be considered. Athletes should
pathophysiological changes and/or
and attention. This can be in the avoid alcohol or other substances
biomechanical forces that occur,
form of questions regarding the that will impair their cognitive
and these have been described in
particular practice or competition, function, and also avoid aspirin and
the literature. The neurochemical
previous game results, and remote other medications that can increase
and neurometabolic changes that
and recent memory, and questions their risk of bleeding.
occur in concussive injury have
to test the athlete’s recall of words,
been elucidated, and exciting As mentioned previously,
months of the year backwards and
research is underway describing the conventional imaging studies such
calculations. Special note should
genetic factors that may play a role as MRI and CT scans are usually
be made regarding the presence
in determining which individuals normal in mTBI. However, these
and duration of retrograde or
are at an increased risk for studies are considered an adjunct
anterograde amnesia, and the
sustaining brain injury. when any structural lesion, such as
presence and duration of confusion.
Most commonly, concussion is A timeline of injury and the an intracranial bleed or fracture, is
characterized by the rapid onset of presence of symptoms should be suspected. If an athlete
cognitive impairment that is self
limited and spontaneously resolves.
Table 1
The acute symptoms of concussion,
SIGNS AND SYMPTOMS OF mTBI
listed below, are felt to reflect a
Loss of consciousness (LOC) Visual Disturbances
functional disturbance in cognitive
Confusion (Photophobia, blurry Phono/
function instead of structural
Post-traumatic amnesia (PTA) photophobia vision,
abnormalities, which is why
Retrograde amnesia (RGA) double vision)
diagnostic tests such as magnetic
Disorientation Disequilibrium
resonance imaging (MRI) and
Delayed verbal and motor Feeling “in a fog,” “zoned out”
computerized tomography (CT) responses Vacant stare
scans are most often normal. Inability to focus Emotional lability
These studies may have their role Headache Dizziness
in assessing and evaluating the Nausea/Vomiting Slurred/incoherent speech
head-injured athlete whenever there Excessive drowsiness
is concern for the associated 53
experiences prolonged loss of
consciousness, confusion, seizure 1. NCAA Concussion Fact Sheets and Video for Coaches
activity, focal neurologic deficits or and Student-Athletes
Available at www.NCAA.org/health-safety.
persistent clinical or cognitive
2. Heads Up: Concussion Tool Kit
symptoms, then additional testing CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.
may be indicated. 3. Heads Up Video
NATA. Streaming online at www.nata.org/consumer/headsup.htm.
There are several grading systems
and return-to-play guidelines in the
literature regarding concussion in
needed to understand the complete
sport (AAN, Torg, Cantu). However, Zurich Conference, NATA ‘04). role of neuropsychological testing.
there may be limitations because
they presume that LOC is associated Several recent publications have Given these limitations, it is
with more severe injuries. It has endorsed the use of neurocognitive essential that the medical care team
been demonstrated that LOC does or neuropsychological testing as the treating athletes continue to rely on
not correlate with severity of injury cornerstone of concussion its clinical skills in evaluating the
in patients presenting to an evaluation. These tests provide a head-injured athlete to the best of its
emergency department with closed reliable assessment and ability. It is essential that no athlete
head injury, and has also been quantification of brain function by be allowed to return to participation
demonstrated in athletes with examining brain-behavior when any symptoms persist, either
concussion (Lovell ‘99). It has been relationships. These tests are at rest or during exertion. Any
further demonstrated that retrograde designed to measure a broad range athlete exhibiting an injury that
amnesia (RGA), post-traumatic of cognitive function, including involves significant symptoms, long
amnesia (PTA), and the duration of speed of information processing, duration of symptoms or difficulties
confusion and mental status changes memory recall, attention and with memory function should not be
are more sensitive indicators of concentration, reaction time, allowed to return to play during the
injury severity (Collins ‘03), thus an scanning and visual tracking ability, same day of competition. The
athlete with these symptoms should and problem solving ability. Several duration of time that an athlete
not be allowed to return to play computerized versions of these tests should be kept out of physical
during the same day. These athletes have also been designed to improve activity is unclear, and in most
should not return to any the availability of these tests, and instances, individualized return-to-
participation until cleared by a make them easier to distribute and play decisions should be made.
physician. More recent grading use. Ideally, these tests are These decisions will often depend
systems have been published that performed before the season as a on the clinical symptoms, previous
attempt to take into account the “baseline” with which post-injury history of concussion and severity
expanding research in the field of tests can be compared. Despite the of previous concussions. Additional
mTBI in athletes. Though it is utility of neuropsychological test factors include the sport, position,
useful to become familiar with these batteries in the assessment and age, support system for the athlete
guidelines, it is important to treatment of concussion in athletes, and the overall “readiness” of the
remember that many of these several questions remain athlete to return to sport.
injuries are best treated in an unanswered. Further research is
Once an athlete is completely
asymptomatic, the return-to-play
Table 2 progression should occur in a step-
SYMPTOMS OF POST-CONCUSSION SYNDROME wise fashion with gradual
Loss of intellectual capacity Fatigue increments in physical exertion and
Poor recent memory Irritability risk of contact. After a period of
Personality changes Phono/photophobia remaining asymptomatic, the first
Headaches Sleep disturbances step is an “exertional challenge” in
Dizziness Sleep disturbances
Lack of concentration Depressed mood to 20 minutes in an activity such as
Poor attention Anxiety biking or running in which he/she
54 increases his/her heart rate and
breaks a sweat. If he/she does not
experience any symptoms, this can The NCAA Executive Committee adopted
be followed by a steady increase in (April 2010) the following policy for
exertion, followed by return-to-
institutions in all three divisions.
sport-specific activities that do not
put the athlete at risk for contact. “Institutions shall have a concussion management plan on file such
Examples include dribbling a ball that a student-athlete who exhibits signs, symptoms or behaviors con-
or shooting, stickwork or passing, sistent with a concussion shall be removed from practice or competi-
or other agilities. This allows the tion and evaluated by an athletics healthcare provider with experience
athlete to return to the practice in the evaluation and management of concussions. Student-athletes
setting, albeit in a limited role. diagnosed with a concussion shall not return to activity for the
Finally, the athlete can be remainder of that day. Medical clearance shall be determined by the
progressed to practice activities team physician or his or her designee according to the concussion
with limited contact and finally full management plan.
contact. How quickly one moves “In addition, student-athletes must sign a statement in which they ac-
through this progression remains cept the responsibility for reporting their injuries and illnesses to the
controversial. institutional medical staff, including signs and symptoms of concus-
sions. During the review and signing process, student-athletes should
be presented with educational material on concussions.”
1. Cantu RC: Concussion severity should and Neuropsychological Performance in 13. Makdissi M, Collie A, Maruff P et al:
not be determined until all College Football Players. JAMA Computerized cognitive assessment of
postconcussion symptoms have abated. 282:964-970, 1999. concussed Australian Rules footballers.
Lancet 3:437-8, 2004. 8. Guskiewicz KM, Bruce SL, Cantu R, Br. J Sports Med 35(5):354-360, 2001.
2. Cantu RC: Recurrent athletic head Ferrara MS, Kelly JP, McCrea M, 14. McCrea M: Standardized mental
injury: risks and when to retire. Clin Putukian M, McLeod-Valovich TC; status assessment of sports concussion.
Sports Med. 22:593-603, 2003. National Athletic Trainers’ Association Clin J Sport Med 11(3):176-181, 2001.
3. Cantu RC: Post traumatic (retrograde/ Position Statement: Management of
Sport-related Concussion: Journal of 15. McCrea M, Hammeke T, Olsen G,
anterograde) amnesia: pathophysiology
Athletic Training. 39(3): 280-297, 2004. Leo , Guskiewicz K: Unreported
and implications in grading and safe
return to play. Journal of Athletic concussion in high school football
9. Guskiewicz KM: Postural stability players. Clin J Sport Med 2004;14:13-
Training. 36(3): 244-8, 2001. assessment following concussion: One
piece of the puzzle. Clin J Sport Med 17.
4. Centers for Disease Control and
Prevention. Sports-related recurrent 2001; 11:182-189. 16. McCrory P, Meeuwisse W, Johnston
brain injuries: United States. MMWR 10. Hovda DA, Lee SM, Smith ML et al: K, Dvorak J, Aubry M, Molloy M, Cantu
Morb Mortal Wkly Rep 1997; 46:224- The Neurochemical and metabolic R. Concensus Statement on Concussion
227. cascade following brain injury: Moving in Sport: the Third International
5. Collie A, Darby D, Maruff P: from animal models to man. J Conference on Concussion in Sport.
Computerized cognitive assessment of Neurotrauma 12(5):143-146, 1995. Zurich, Switzerland, 2008. Br J Sports
athletes with sports related head injury. 11. Johnston K, Aubry M, Cantu R et al: Med 2009;43:i76-i84.
Br. J Sports Med 35(5):297-302, 2001. Summary and Agreement Statement of 17. Torg JS: Athletic Injuries to the Head,
6. Collins MW, Iverson GL, Lovell MR, the First International Conference on Neck, and Face. St. Louis, Mosby-Year
McKeag DB, Norwig J, Maroon J: On- Concussion in Sport, Vienna 2001, Phys Book, 1991.
field predictors of neuropsychological & Sportsmed 30(2):57-63, 2002. 18. Langlois JA, Rutland-Brown LV, Wald
and symptom deficit following sports- 12. Lovell MR, Iverson GL, Collins MW MM. The Epidemiology and Impact of
related concussion. Clin J Sport Med et al: Does loss of consciousness predict Traumatic Brain Injury. J Head Trauma
2003; 13:222-229. neuropsychological decrements after Rehabil. 2006; 21:375-8.
7. Collins MW, Grindel SH, Lovell MR et concussion? Clin J Sport Med 9:193-
al: Relationship Between Concussion 198, 1999. 55
In Addition to the Executive Committee Policy Requirements,
Additional Best Practices for a Concussion Management Plan
Include, but are not Limited to:
1. Although sports currently have rules in place, for each student-athlete before the first practice
athletics staff, student-athletes and officials should in the sports of baseball, basketball, diving,
continue to emphasize that purposeful or flagrant equestrian, field hockey, football, gymnastics,
head or neck contact in any sport should not be per- ice hockey, lacrosse, pole vaulting, rugby,
mitted and current rules of play should be strictly soccer, softball, water polo and wrestling, at
enforced. a minimum. The same baseline assessment
tools should be used post-injury at appropriate
2. Institutions should have on file and annually update
time intervals. The baseline assessment should
an emergency action plan for each athletics venue
consist of one or more of the following areas of
to respond to student-athlete catastrophic injuries
assessment.
and illnesses, including but not limited to, con-
cussions, heat illness, spine injury, cardiac arrest, 1) At a minimum, the baseline assessment should
respiratory distress (e.g., asthma), and sickle cell consist of the use of a symptoms checklist and
trait collapses. All athletics healthcare providers standardized cognitive and balance assess-
and coaches should review and practice the plan at ments [e.g., SAC; SCAT; SCAT II; Balance
least annually. Error Scoring System (BESS)].
3. Institutions should have on file an appropriate 2) Additionally, neuropsychological testing (e.g.,
healthcare plan that includes equitable access to computerized, standard paper and pencil) has
athletics healthcare providers for each NCAA sport. been shown to be effective in the evaluation
and management of concussions. The develop-
4. Athletics healthcare providers should be empowered
ment and implementation of a neuropsycho-
to have the unchallengeable authority to determine
logical testing program should be performed
management and return-to-play of any ill or injured
in consultation with a neuropsychologist who
student-athlete, as the provider deems appropriate.
is in the best position to interpret NP tests by
For example, a countable coach should not serve as
virtue of background and training. However,
the primary supervisor for an athletics healthcare
there may be situations in which neuropsy-
provider, nor should the coach have sole hiring or
chologists are not available and a physician ex-
firing authority over a provider.
perienced in the use and interpretation of such
5. The concussion management plan should outline testing in an athletic population may perform
the roles of athletics healthcare staff (e.g., physician, or interpret NP screening tests.
certified athletic trainer, nurse practitioner, physician
d. The student-athlete should receive serial
assistant, neurologist, neuropsychologist). In addi-
monitoring for deterioration. Athletes should be
tion, the following components have been specifi-
provided with written instructions upon dis-
cally identified for the collegiate environment:
charge, preferably with a roommate, guardian or
a. Institutions should ensure that coaches have ac- someone who can follow the instructions.
knowledged that they understand the concussion
e. The student-athlete should be evaluated by a
management plan, their role within the plan and
team physician as outlined within the concus-
that they received education about concussions.
sion management plan. Once asymptomatic
b. Athletics healthcare providers should practice and post-exertion assessments are within normal
within the standards as established for their baseline limits, return-to-play should follow a
professional practice (e.g., physician, certified medically supervised stepwise process.
athletic trainer, nurse practitioner, physician as- 6. Institutions should document the incident, evalua-
sistant, neurologist, neuropsychologist). tion, continued management and clearance of the
c. Institutions should record a baseline assessment student-athlete with a concussion.
For references, visit www.NCAA.org/health-safety.
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