Teen Health Supervision


A concussion is a mild traumatic brain injury which results in an alteration in neurologic function or mental status that may (or may not) involve loss of consciousness. Typically, symptoms have rapid onset, are short-lived, and resolve spontaneously. Mild concussions are commonly known as "dings" or "having one's bell rung." It was common practice to return athletes to the same game following a cursory exam and resolution of most symptoms but it is now known that such athletes are less able to protect their head and neck, and are more susceptible to sustaining additional injuries.

Post-concussion syndrome (PCS) is a common sequela of traumatic brain injury manifested by headaches, dizziness, vomiting, fatigue, irritability, difficulty focusing, disorientation, incoordination and memory problems. Symptoms of PCS are greatest in the first 7-10 days following the concussion, with most cases resolving completely by 1-3 months.

Chronic traumatic encephalopathy (CTE) is a concern for athletes who receive repeated concussions. There is some evidence that repeated head injuries cause cumulative damage, with worsening severity and duration after each event. CTE results in chronic neurologic impairments including behavior and personality changes, parkinsonism, and cognitive abnormalities.

Second-impact syndrome refers to a rare condition in which an athlete develops diffuse cerebral edema from a second head injury while still symptomatic from an earlier concussion. The cause is unknown and is frequently fatal. Second-impact syndrome has driven strict return to play recommendations following concussion.

The current standard of care for returning to play after a suspected concussion is based upon the Zurich Guidelines (see table below). The foundation of the protocol requires that athletes become asymptomatic from their head injury before attempting any return to sports. One method of quantifying concussion symptoms during evaluation is to use a symptom checklist such as the Sideline Concussion Assessment Tool (SCAT3).    

Once the athlete is asymptomatic, clinicians should initiate a step-by-step return to play process. Each step consists of an increasing level of activity and 24 hours minimum between each phase. If symptoms return during the process, the athlete should rest for at least 24 hours and return to the last successfully completed step before trying again to proceed.  






 0 - No activity


 Physical and mental rest


 1 - Light aerobic exercise


 Walking, swimming, or stationary cycling. Increase heart rate to <70% of maximum predicted


Increase heart rate

 2 - Sport-specific exercise


 Non-contact sports activities increasing heart rate >70% of predicted


 Add movement

 3 - Non-contact training drills

 Non-contact sports activities with more complex drills. May start weightlifting.


Advance coordination and increase exercise

 4 - Full contact practice

 Following medical clearance, return to normal training activities

Restore confidence, assess functional skills by coaching staff


 5 - Return to play

 Full game play

 Full participation