Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Filtering by Tag: concussion advocacy

Complete Rest After Concussion May Not Be Best Prescription

This report from the 2016 Pediatric Academic Societies meeting adds to a growing body of evidence suggesting that children who get low risk exercise even while still having post-concussion symptoms may actually have shorter recovery periods.

One may rightfully wonder if there is some selection bias in these results- kids who may have felt less burdened by concussion symptoms naturally tried to return to exercise sooner. Further study will have to explore this potential phenomenon.

Overall, I think these findings and the outcomes of similar studies provide support for a more active post-concussion recovery monitored by qualified health care providers and not just predicated on rest and watchful waiting.

The proper time to start such active recovery is not certain and likely will be an individual matter as well.

This does also bring up the fact that many current concussion return to sport policies recommend or even require that athletes must be symptom-free before being allowed to return to any form of exercise.

If continued study indeed adds support to the role of appropriately monitored and prescribed exercise to enhance recovery, then these policies, such as the California Interscholastic Federation return protocol, will need to be amended.

Rather than a "one size fits all" uniform pathway, allowing some measure of flexibility may also provide beneficial when determining starting points and type/amount of exercise.

Otherwise medical experts and school officials are possibly restricted in utilizing exercise to aid in recovery and this limitation may actually be slowing the improvement of concussed athletes.



Dr. Koutures Thoughts on US Soccer Youth Heading Recommendations via MomsTEAM

On November 9, 2015, as part of a concussion-based lawsuit settlement agreement, the United States Soccer Federation (USSF) announced a series of recommendations directed at identification, management, and prevention of concussions in youth soccer.

In regards to youth players heading a soccer ball, the following recommendations were released:

  • Under age 11(U11) and younger
    •  U.S. Soccer recommends that players in U11 programs and younger shall not engage in heading, either in practices or in games
  • U12 and U13
    • U.S. Soccer further recommends for players in U12 and U13 programs, that heading training be limited to a maximum of 30 minutes per week with no more that 15-20 headers per player, per week.
  • All coaches should be instructed to teach and emphasize the importance of proper techniques for heading the ball.

As one of the co-authors of the 2010 American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness Policy Statements on Injuries in Youth Soccer, I responded to questions posed by Lindsey Barton Straus, JD of MomsTEAM  about certain aspects of these heading recommendations. Please click on the above link to read her entire article and my embedded comments which represent my opinions and may not be interpreted as official AAP policy.

Be on the lookout for a follow-up article from MomsTEAM that reviews return to play decision-making components of the settlement agreement 

Less Football Practice Contact Time May Mean Less Concussions

In the evolving discussion regarding the impact of limited high school contact football practice time on concussion risk, findings from the University of Wisconsin suggest that less contact practices may indeed result in less football-related concussions.

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The state of Wisconsin was one year ahead of California in mandating contact practice time restrictions. Starting with the 2014 high school fall season, the Wisconsin Interscholastic Athletic Association (WIAA) prohibited contact in practice for the first week and limited full contact to 75 minutes per week for week 2, with 60 maximum minutes per week for week three and beyond. These limits are more restrictive than in California where two 90 minute contact practice sessions are allowed per week during the high school football season, thought the definitions of full contact are similar (game speed drills/situations where full tackles are made at competitive pace and players are taken to the ground).

Licensed Athletic Trainers at several Wisconsin high schools recorded incidence and severity for each sport-related concussion, and compared the two years previous to the rule change (2081 players) with data from the first year of the new limitations (945 players). 

Significant findings included

·        The rate of sport-related concussion sustained in practice was more than twice as high in the two seasons prior to the rule change

·        There was no change in the rate of concussion suffered in games pre and post-rule change

·        There was no difference in the severity of concussion (defined as average days lost from football activity) pre (13 days lost) and post-rule change (14 days lost)

·        Tackling was the primary mechanism of injury in 46% of sport-related concussions

·        Years of football playing experience did not affect the incidence of sport-related concussion in the first year of the new limitations

The authors concluded that limitations on contact during high school football practice may be one effective measure to reduce the incidence of sport-related concussion

How might this relate to California?

This is a well-constructed and much needed initial evaluation on the outcomes of contact practice reductions in high school football, with subsequent years of analysis now being anticipated to see if the above findings hold true over multiple seasons.

The maximum allowed football contact times in Wisconsin are about 42% of the maximal time currently allowed in California, so one may wonder if that increased contact time may make direct extrapolations between the states more difficult. This is where a similar study after the 2015 California high school season is vital to measure the outcomes here in this state.

I was greatly impressed with the finding that there was no change in game-based concussion rate and that the years of previous playing experience not affecting the incidence of new concussion as two potentially landmark outcomes for the future of football safety.  Coherent arguments have been voiced that lack of appropriate contact practice time might increase risk for inexperienced or under-prepared players, especially in game time situations. This was particularly voiced for freshman players with no previous tackle football experience. I eagerly await future studies to see if these outcomes are consistent and robust.

The lack of change in severity (again, measured in days lost) brings up a couple of thoughts. The initial reaction might be a bit of disappointment, in that reduction of cumulative head impacts in practice should perhaps lead to a lower burden of injury with a concussive blow and hopefully a quicker recovery. One may not want to try and read much into using number of days lost as a strong measure of severity, for standard return-to-play protocols often mandate a minimum of 8-10 days off from full activity which could influence the return time possibly more than symptoms and other measures of severity.

One important subject not analyzed in this study was the incidence of non-concussion injury rates before and after the practice contact limits were enacted. Concerns have been issued over under-prepared players not confident in tackling techniques or changes in technique (hitting opponent lower in body, for example) both possibly contributing to less concussions, but more shoulder, elbow, knee, leg and other musculoskeletal injuries. 

Curious if any groups in California are interested or have proposed a similar analysis of our first year with the high school football practice limitations?

Reducing Injury: Focus on Exam Schedule as Much as Game Schedule?

The following blog post was originally written for a collegiate audience for, but the theme of exam stress increasing injury risk applies to all student-athletes. Please read through to the end for some additional thoughts on the link between academic burdens and injuries.

While most collegiate athletes and coaches dissect game schedules as a matter of habit, taking time to analyze exam schedules could pay off in reduced injury and illness risk. 

This news is probably not too surprising for many collegiate athletes who would readily acknowledge that any time of increased stress lead to a higher risk of injury.

Physical stress burdens are more readily acknowledged in pre-season training periods, often noted for two-a-day practices and passionate efforts to make the team or earn a starting position.

Often once taxing practices come to an end, many will take a collective deep breath and figure "the worst is behind me". While reading, writing papers, and taking exams is no walk in the park, those academic efforts seemingly should be less of a burden than heavier practice loads.

Well, perhaps those mental stressors present a fairly similar, if not higher risk to their physical counterparts.

Thanks to some inquisitive work at the University of Missouri, collegiate football players were 3.19 times more likely to have an injury restriction during weeks when they had high academic stress, such as midterms or finals, than during weeks where they had low academic stress. This increased injury risk during periods of academic stress was more noted in starting players, and the overall risk of academic stress was actually a bit higher than the injury restriction risk from physical stress during training camp (2.84 times higher risk compared to a low academic stress week).

These findings are from college football, where pre-season practice sessions take place before the academic year begins. Imagine the results for a winter sport like basketball or wrestling, where more intense pre-season sessions take place during the fall term academic sessions. Can anticipate a higher overall burden of physical and mental stress if mid-term exams (and papers) are due during heavier audition or training periods.

While it is virtually impossible to eliminate academic stressors or completely re-align practice or game schedules to better account for  mid-term and final exam periods, some creative suggestions could attempt to reduce the cumulative physical and mental burden for collegiate athletes:

  • Making reduction in overall practice times, reducing more demanding conditioning sessions, and focusing on maintenance of previous learned skills/techniques while holding off on introduction of new items could be rewarding. This might have to be done on an athlete-by-athlete basis depending on particular academic schedule demands. While this might appear to place a onerous burden on coaching and training staffs,  it is in line with the growing fascination with "big data" and more individualized training and recovery programs.
  • For athletes who are experiencing higher levels of physical or mental unease even before exam periods, recommend earlier intervention with mental health specialists and medical staff. As the study authors recommend, coaches should watch the attitudes of their athletes. If attitudes head south, be alert and ask for exam concerns among other stresses.
  • Take advantage of flexibility afforded by on-line learning or open exam periods to schedule exams or assignments to be due during possible bye weeks, weeks without travel, or a week with limited or reduced competition.
  • Work with winter or spring sport teams to give plenty of advance notice for audition or heavier practice periods to allow any possible rescheduling of mid-term exams.

I have also seen a relationship between academic stress leading to both new injury risk or more often prolonged healing times after injury especially in middle school and older patients.

When patients and families ask about adding new activities to their schedule, or how to pace a return to play after an injury, I will routinely ask about school demands (exams, papers, projects). Periods of heavier academic load are probably not the best time for increased or new training. Especially in cases of a concussion, I will often recommend waiting until academic demands are completed before allowing further return to high-risk sporting activity.









New Location: Orange County Return to Learn after Concussion Conference

Designed for classroom educators, administrators, counselors, special education specialists, school nurses, speech/language pathologists, athletic trainers, and other parties who work with student-athletes after concussion.

Featuring renown speaker  Brenda Eagen Brown who will offer practical suggestions based on real-world situations supported by the latest evidence-based research.

I will join other local concussion specialists in a lunch period case-based discussion of return to learn challenges.

Dr. Koutures Quoted on Concussed College Athletes Choosing Early Retirement

Never easy for anyone to have to give up a sport and often the "athlete" sense of identity.

In a thoughtful and well-written article from Inside Higher Ed, Jake New weaves many perspectives on early retirement after concussion.

Highly recommend the read!

New California Football Contact Limits Provide Unique Opportunity to Study Effect on Concussions

According to the findings of a study published in the May 4th online edition of JAMA Pediatrics, practice periods are a major source of concussion for the high school football player

While the actual rate of concussion is higher in game play, just over half of the reported concussions took place during practice times.

The authors suggest that strategies should be implemented to evaluate technique, limit player-to-player contact and overall head impact exposures, and reduce other higher risk practice situations.

While the jury is still out on what constitutes proper technique, the mandates of California Assembly Bill 2127 will afford a vital opportunity to further study the influence of practice time limitations on concussion rates in high school football players.

The bill prohibits high schools from conducting more than 2 full-contact practices per week during the preseason and regular season, and prohibits this full-contact portion of the practice from exceeding 90 minutes in a single day.

To clarify, "full-contact practice" means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game.

Based on the findings of the above JAMA Pediatrics study, the hypothesis is that these new restrictions should reduce concussion rates in practice simply by limiting exposure time and cumulative risk.

Now, one might ask, why would there possibly not be a reduction in concussion rates?

  • Is there a chance that limited practice times could lead to less comfort with tackling that could result in an actual higher game rate of concussion?
  • Could football programs feel pressure to get in as much contact as possible during the 2 allocated 90 minutes practice periods, possibly leading to more cumulative exposure during that time?

A multi-location review of concussion rates (game and practice) is essential to confirm the effects of California AB 2127. 

In such a study, I would also suggest that concussion rates be broken down by academic grade of player, and even take into account years of experience of tackle football.

I wonder if neophytes (namely incoming freshman) who have never previously played tackle football could be at higher risk from contact practice time limits.  Would the contact time restrictions have less influence on upperclassman who have played tackle football for a longer period of time?

All stakeholders will be eager to see if indeed there is a documented reduction in overall concussion rates, and if such a reduction is seen across all levels of high school football.

Are Past Unreported Concussions Often Found in Pre-Season Assessments?

The use of baseline assessments to provide comparison data for future concussions provokes controversy about validity, cost, and time investment. If however, such testing routinely uncovered past unreported or even currently symptomatic concussions, would that influence opinions about the significance of such efforts?

Definitely curious if others have found significant numbers of previously unrecognized concussions in their preseason testing?

I met recently with administrators of a local contact/collision sport league who wanted to discuss their pre-season baseline testing program for concussion monitoring.

They have developed an amazing concussion program, complete with education, pre-season testing, surveillance, and return-to-play protocols.

Coaches or team administrators are required to report all suspected or confirmed concussions to league officials for follow-up monitoring of medical evaluation, treatment, recovery and return progression.

The leagues they supervise are growing, with now over 1000 athletes on multiple teams in several cities.

That means the potential of more pre-season evaluations, and whether the medium is computer or paper based, with or without functional testing such as vestibular or visual testing, we all know that this takes time, effort and tends to have a bunch of logistical issues.

So, not unacceptable to find ways to reduce the early season demands but still provide adequate data to analyze players after a concussion.

With the ability to compare post-injury results to solid age-matched normative data sets for many of the neurocognitive platforms, some have begun to question the utility of the time and expense for routine annual baseline testing.

Others have offered the opinion that every other year evaluations might suffice in the school-aged population and thus reduce some of the testing burden but not lose the value of the data.

These both sounded like workable options for this league to consider, until one eye-popping revelation was shared.

Realize, we're talking about a close-knit sport community where kids and families know each other well and administrators have designed a visible program that requires reports of all potential concussions, with penalties in place for failure to report.

You’d think that there wouldn’t be too many concussions that could sneak by so many watchful eyes.

Guess again.

A critical review of the pre-season data found a startling disconnect on many teams between the number of concussions officially reported to the league and the number of concussion the kids report in their baseline testing.

When asked to report either number of concussions or current possible post- concussion symptoms, the players admitted to a frankly startling number of concussions, including dates of injury, that were never officially entered into the league data base.

Now perhaps this shouldn’t have been so surprising to those of us having this conversation.

We always worry about under-reporting at the time of injury, not just by athletes, but also unfortunately by adult coaches and parents all eager to limit or eliminate any missed playing time.

Have also learned another thing when working with kids- when it comes to answering questions about symptoms or past concussions, kids just can’t seem to lie to a computer..

They might repeatedly deny past history or current problems to a medical provider in person, but when asked to report information to a computer, the flood gates tend to open.

I must give big-time credit to these league officials for underscoring the importance of their active, critical review of all baseline testing and not just passively collecting data for potential future use.

Their use of the computerized baseline testing information apparently allowed a better look at the true incidence of concussions, and unfortunately, a more realistic look at sandbagging or failing to report.

Now, I’m not entirely ready to endorse a punitive Orwellian “1984: Big Brother is Watching” approach to concussion management.

I still think trust and transparency between all parties is absolutely essential.

I’m also not totally on board with the absolute need for computer-based platforms for concussion evaluation or record keeping for that matter (often handwritten mediums provide sufficient information).

But if an annual computerized pre-season assessment  provides candid responses that reveal sufficiently high numbers of previously unreported or even worse, incompletely healed concussions, then maybe all that work, all that effort, and all those logistical efforts suddenly seem far more justified.

Very curious if other organizations performing large-scale pre-season baseline neurocognitive evaluations have seen a similar difference between “official” concussion reports and those self-reported on computerized assessments?

Is the above experience an isolated phenomenon, or is it worthy of further collaborative study?

Why University Athletes May Hide Concussion Symptoms

I often encounter athletes who continue to practice or play in a game despite suffering concussion signs and symptoms and since hiding this information is not considered advisable and potentially quite dangerous,  have to admit that my initial response is along the lines of "what were you thinking?"

We as medical professionals have a pretty set initial response to a concussion- any suspicion of concussion, immediately remove from activity.

Pretty certain that athletes may view the initial response to concussion in a different light than us medical types.

As I find myself more often hearing of athletes hiding symptoms, my response still is a "what were you thinking?" but rather than asked in a frustrated or ready for a lecture tone, it is asked more in a sense of wanting to appreciate their mindset.

Is it lack of appreciation for the risks of concussion? How about denial? What about worry about losing a role on the team or not wanting to "bother" anyone?

Thus, it was interesting to see that Delaney and colleagues addressed this issues with their study Why University Athletes Choose Not to Reveal Their Concussion Symptoms During a Practice or Game.

The objectives of this paper were to  better understand why athletes who believe they have suffered a concussion while playing their sport “hide,” or decide not to volunteer, their symptoms to medical staff by identifying:

  • specific reasons why athletes who believed they had suffered a concussion during a game or practice decided not to seek attention from medical staff at that time, how often these reasons occurred, and how important these reasons were in the decision process
  • whether there were individual variables that may have made an athlete more likely to not volunteer his or her symptoms to a therapist/trainer or physician during a game or practice.

Findings of anonymous questionnaires that asked only about "self-diagnosed" concussions revealed that almost 20% of the 469 males and female athlete respondents believed they had suffered a sport-related concussion within the past 12 months. Of great interest was the fact that 78.3% of those athletes reporting a concussion did not seek medical attention either during the practice or game.

Why not?

Main reasons for "keeping quiet" were:

  • “Did not feel the concussion was serious/severe and felt could still continue to play with little danger" 
  • "Had similar symptoms of a concussion in the past and felt that there was little or no danger as had no problems with previous concussions or similar symptoms in the past"
  • "Fear that being diagnosed with a concussion would affect standing with the current team or future teams”
  • “Fear that being diagnosed with a concussion would result in negative of repercussions from the coach or coaching staff”
  • "Felt that would be removed from the game by the medical staff and did not wish this to happen”
  • “Fear that being diagnosed with a concussion would result in missing future games"

So, it appears that common human emotions- denial, minimalization and fear- are playing a big role.

All are understandable and none aren't surprising.

Not saying that they legitimize hiding symptoms or make it acceptable practice.

But rather they give unique insight into the psyche of university athletes and perhaps open particular in-roads to improving the culture of reporting concussion symptoms.

We need to recognize the fear of being removed, and attempt to address this fear by underscoring importance of early admission and treatment hopefully leading to a less complicated recovery and potentially an appropriately quicker return.

We need to have teams and coaches limit any negative responses to concussion diagnoses and provide essential support to any concussed or any injured athlete for that matter.

We need to acknowledge the competitive drive of our athletes and channel this into a competitive drive to protect their brains by offering such comprehensive diagnostic and management programs that athletes wouldn't think of missing out on getting such essential care.






Thoughts on California Interscholastic Federation Concussion Return Protocol

Right before California Assembly Bill 2127 became law on January 1, 2015, I wrote on this blog many questions remained unanswered about certain provisions, namely clarifying what is meant by "no less than a seven day" return progression, when does this seven day period begin, and a better definition of appropriate supervision during this period.

Today, after reviewing the recently released California Interscholastic Federation (CIF) Concussion Return to Play Protocol, it is now readily apparent that the intent of the law was to ensure that if an athlete was concussed let's say on a Friday night, that they will not be able to return to play the following Friday night.

This comes as no great surprise to many of us in the sports medicine community and serves to bring uniformity to something that we had suspected since the bill was signed into law.

There are several other provisions of the Return to Play progression that should be of unique interest, and I will list them below along with my professional comments:

  • Return to play cannot be sooner than 7 days AFTER the diagnosis of a concussion by an physician MD/DO
    • Now we know when the "clock can start" and what concerns me is not so much the sports with one game a week, but those with multiple games a week.
    • If a football player is concussed on Friday night, having the physician evaluation the following Monday or even Thursday doesn't have a real time sensitivity since that athlete is out for that next week's game and still has the seven day period potentially available to play in the following weeks game.
    • However, let's take the case of a basketball player with a tournament that involves key games possibly 8-9 days after a concussion. There might be pressure placed on the physician to see that athlete ASAP to get the clock started for a potential return in that 8-9 day period
  • No physical activity for at least 2 full symptom-free days AFTER you have seen a physician 
    • Given the emphasis on the no return within a full week after a concussion, can certainly see why this element was put into place.
    • Does limit the judgement of medical teams to allow light, low-risk activities that might be well-tolerated in the initial post-concussion period and may also actually assist in that recovery.
  • A certified athletic trainer (ATC), physician, or identified concussion monitor (e.g., coach, athletic director), must initial each stage successfully passed
    • Leads to an increase in the paper trail but also makes each school responsible for monitoring a step-wise return to play and not just allowing a full immediate return to sport. 
    • Hopefully this provision will further underscore the important role of a certified athlete trainer on a school campus. For those schools that don't have one, this might serve as a strong motivator to find necessary resources to support the hire of an ATC to help maintain compliance with this new law.
  •  Minimum of 6 days to pass (non-contact) Stages I and II. Prior to beginning (contact) State III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor. 
    • That 6 day minimum again written with a direct eye on football and not having an athlete return for that next game after a concussion
    • Here's another spot where having an ATC can make the process easier- as a physician, if I have a strong working relationship with an ATC, I might not need to see the athlete back in my office before allowing return to contact if the ATC is comfortable with the return protocol and progress of the individual athlete.
    • Now, if there is no ATC on campus, stronger chance that I will require an office visit between non-contact and contact return.
  • MANDATORY: You must complete at least ONE contact practice before return to competition. (Highly recommend that Stage III be divided into 2 contact practice days as outlined above.) 
    • Remember that AB 2127 also limits full contact  practices to only 2 ninety minute sessions per week. 
    • Curious to see how a return to play that recommends 2 contact sessions works out with these new contact practice limitations

I will close out this post with a  passionate request to CIF and the sports and school communities: despite any concerns or disagreements, this protocol is now in place and thus must be publicized, discussed and shared through multiple mediums to get the word out to all coaches, athletes, parents, administrators, and medical providers. . I can honestly say that with past state or CIF concussion policy updates, I was shocked at how often reasonable, involved, and usually well-informed colleagues were unaware or ignorant of these changes. If all schools are following the same protocol, there will be more universal acceptance of this new policy, so CIF cannot passively oversee dissemination, it must take a very active and vocal role to increase the appropriate use and eventual greater acceptance of this new protocol.



Studying Role of High School Principals in Return to Learn after Concussion

If there isn't enough frustration and feeling of being overwhelmed after suffering a concussion, the process of returning a student back to academic work can only seem to magnify those concerns.

While return-to-play progression protocols have been established to assist in getting athletes back to sport, similar return-to-learn programs have lagged behind.  The sheer complexity of  meeting particular needs and schedule demands of each student requires an individualized plan created with appropriate understanding of expectations and optimal communication between medical professionals, families and educators.

Often, recommendations include  designating a point person who can advocate for the student and family by communication with fellow educators and monitor of student progress.  This same person might also provide on-going dialogue with outside medical providers. However, finding a person with appropriate knowledge and desire to accept and carry out these roles can be difficult. 

A school-based concussion management and response plan can provide further framework to delineate expectations, potential adjustments, and roles, though the actual implementation and utility of such plans has not received much study.

Given the common findings of frustration and lack of apparent coordination in the return to learn process, I was excited to review the article HIgh School Principals' Resources, Knowledge, and Practices regarding the Returning Student with Concussion  in an effort to gain unique and previously unreported insight into school-based resources and management strategies.

Using a cross-sectional computer-based survey of 465 urban, suburban, and rural public high school principals in the state of Ohio, key findings of this study included:

  • Just over 1/3 of the principals had completed some form of concussion training in the past year, with those who completed such training have higher self-reported concussion knowledge scores and were more likely to have provided or supported concussion training for school faculty who were not directly involved with youth sports
  • When identifying a point person, athletic trainers were most often reported, but about 1/5 of respondents did not know or designate a point person at their school. Schools that identified  more than one point person tended to  have more students, a principal with higher self-reported concussion knowledge, and to have a full or part-time athletic trainer.
  • Athletic trainers were reported as the main agents of communication with medical professionals for concussed student-athletes, while school nurses and counselors assumed this role for concussed students who were not athletes. Principals, assistant principals, and guidance counselors assumed the primary role of communication with parents for all students  (regardless of athlete status).
  •  When asked to respond to a list of short-term classroom adjustments commonly recommended for concussed students, over 90% of principals agreed with all or most of them, with just over 30% requiring a health care provider note to initiate the adjustments.
  • Several principals reported a school response-to-intervention (RTI) team to assess student needs and to develop an intervention plan in terms of academic adjustments and accommodations.
  • About 1/3 of the schools had a written concussion plan, with 75% of those plans addressing academic adjustments and accommodations.

How can we use these findings to better assist our concussed students in their effort to return to the classroom?

  • A principal with concussion knowledge is essential- thus ensure more (and hopefully higher quality) concussion training for principals, which could then translate to more training for school personnel, the identification of point persons to assist concussed students, and better communication between principals and the parents of a concussed athlete.
  • An athletic trainer is essential- thus ensure that every high school campus has a  certified athletic trainer acting as an advocate for concussed students and being on campus for part/all of the academic day (not just for after-school activities) to foster relationships with teachers and help monitor student developments.
  • An intervention team is essential to initiate academic adjustments early after a concussion, preferably without the absolute need of a medical provider note to reduce any obstacles.
  • Providing a concussion management plan that delineates roles and expectations and is shared with all key parties (students, school personnel, families and medical providers) to provide education and on-going assessment of the utility of the plan.

What other recommendations do you have to assist concussed students return to learn? Do these recommendations seem reasonable and practical?



Sleep, Screen Device Use, and Concussion Recovery

Each concussion deserves individualized recommendations that seek to strike the delicate balance between a child's need for maintaining social contacts and attempt to continue with school work with a desire to not overwhelm the healing brain and increase post-concussion symptoms. An absolute restriction on screen use might reduce possibility of certain symptoms such as difficulty falling or staying asleep, but can also lead to social isolation contributing to higher symptom reports of anxiety, sadness, and outright depression. 

How can we best strike an appropriate balance between screen use and need for adequate sleep?

Ask most parents if they have worries about sleep issues and amount of electronics/screen device use in their school aged children, and you'll probably get ready nods and smiles of affirmation. 

Ask some of my sports medicine colleagues about why we are seeing more complicated and prolonged post-concussion recoveries, and you'll hear some suggest that the multi-tasking and multiple platforms of communication utilized by smart phones and other screen devices are potential contributing factors.

So since increasing sleep issues and attempts to pry screen-based devices from the hands of kids are common concerns to parents and medical professionals, it should be no surprise that difficulties initiating or maintaining sleep and regulating electronic use are often major challenges in children who have suffered a concussion.

Came across two recent studies on the subject of screen use and sleep that I think shed some interesting light on how we might make recommendations for all children, but particularly in the immediate post-concussion population.

One study from Proceedings of the National Academy of Sciences of the United States of America suggests the use of portable light-emitting devices immediately before bedtime has potential biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety. Such device use can:

  •  increase alertness at bedtime, which may lead users to delay bedtime at home
  •  suppress levels of the sleep-promoting hormone melatonin,
  •  reduce the amount and delays the timing of REM sleep
  • and reduce alertness the following morning

While this study used healthy young adults (mean age around 25 years of age), the findings are intriguing enough to be extrapolated to younger patients. Given the frequency where recommended oral melatonin clearly helps with falling and staying asleep, having another pathway to support internal melatonin production can be essential in the recovery process.

An additional study from the journal Pediatrics examined 4th through 7th graders and assessed associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. Particular interest was placed on smartphones which can emit notifications during sleep periods, and relevant findings included:

  • Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations.
  • Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep.

These findings found that small screens could have more adverse effects on sleep than television screens and thus caution against unrestricted screen access in children’s bedrooms for normal, healthy 4th through 7th graders, which again could be extrapolated to include concussed children.

Throwing this all together, a pragmatic approach to screen use after concussion that utilizes the findings of these studies may include the following clinical recommendations:

1) The preponderance of screen devices is an integral reality in the life of many school-aged children and significance of appropriate use cannot be underestimated in expediting post-concussion recovery.

2) Once appropriate, limit screen device time use initially to the middle of the day and not within one hour of any scheduled nap or evening sleep period.

3) All screen device use should be stopped at least one hour before bedtime,

4) Screen devices should be removed from the bedroom to reduce interruptions in sleep from notifications or temptation to check devices for updates during periods of awakening.

Once the child has recovered from the concussion, the child might find that continuing the above screen time recommendations may lead to continued enhanced amount and quality of sleep, which in itself may lead to an enhanced quality of life. On-Campus Resources After Concussion

Thanks to colleagues from for publishing my blog post focusing on resources for disabled students on college and university campuses, particularly for student-athletes recovering from concussions.

Check out the blog post and a host of concussion-related resources at

Are California Schools and Medical Providers Prepared for New Concussion Law?


California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) will take formal effect on January 1, 2015 and will provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

  • Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
  • Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
  • Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
  • Concussion education must now be part of required first aid training of every high school coach

For my initial reaction to this law, click here

In discussions with coaches, administrators, and fellow sports medicine providers, I'll throw out a few questions that have arose regarding several nuances of the law:

  • When is the earliest that the 7-day return protocol begins?
    • Is it potentially at the time of formal diagnosis of a concussion by a licensed provider?
    • Is it when the athlete is fully cleared of post-concussion symptoms?
    • Can the period begin before a formal diagnosis is made?
  • What is the formal definition of supervision?
    • Can an athletic trainer assume the role of supervision under the guidance of a physician?
  • Given that the bill also limits contact football practices to two 90 minute periods per week, if the timing of those two practices is perhaps a day before a player's progression is ready for contact, can he have alternate contact to possibly play in a game if otherwise having an appropriate recovery?
  • Are school and medical providers aware and sufficiently prepared for these new edicts?
    • Is there agreement or clarification on the above terms and concerns?
    • Have concussion management plans, if already in place, been modified or reviewed to address the new mandates?

Certain that there are other questions and thoughts out there- please use this as a forum to share with others.


Pre-Concussion Mood Disorders May Lead to Prolonged Post-Concussion Recovery

In an effort to better identify young athletes who might be a greater risk of prolonged recoveries after suffering a sport-related concussion, the findings of a recent retrospective study indicate that a personal or family history of mood disorders maybe linked to a longer recovery period.

Researchers at Vanderbilt University compared athletes who had a three week post-concussion symptom resolution period versus those with a three month or longer symptom recovery period, and found that those with pre-concussion anxiety or depression had a 17-fold increased risk of having the prolonged recovery time.

The research team also found that a family history of mood disorders and delayed onset of symptoms were both also associated with an increased risk of prolonged symptoms after a sport-related concussion.

These findings definitely mirror my experiences in working with school-aged athletes who have suffered concussions during sport activities. 

I am more apt to ask about both personal and family history of mood disorders, often in the initial evaluation after a concussion. I will counsel families that any diagnosed or even suspected pre-existing emotional disorder, including Attention Deficit Disorder with/without Hyperactivity (not evaluated in the above study), depression and anxiety will have a tendency to worsen after concussion. 

In some cases, it is the concussion that makes pre-injury issues more clear and out in the open, and in those instances, we both have to manage the concussion issues but also give proper respect and attention to those underlying mood disorders. 

Early identification and aggressive psychological, medical, and school-based interventions are quite helpful in addressing emotional disorders. Key to have mental health colleagues available to assist in more difficult cases.

Failure to address the mood disorders leads to sub-optimal recovery.

I have also found that those pre-existing emotional disorders optimally managed with appropriate therapy and medication (when indicated) tend to have less consequences or flare-ups after an concussion. 

The findings of delayed onset of symptoms is also not a major surprise. I do tend to see namely depressive symptoms not fully present for up to 4-6 weeks after a concussion. Not sure why this occurs. Could be part of the anticipated physiologic healing response, but could possibly be a by-product of cumulative mental and physical  fatigue that accumulates by this time period and results in higher reported symptom presentations.





Addressing the Social Impact of Retiring from Sport due to Concussion

My wonderful colleagues at Concussion Connection have been offering their expert perspectives on retirement from sport due to concussion, and I am pleased to offer thoughts on the Social Impact of Retiring. Strongly recommend checking out the entire Concussion Connection site and praise them for the fine work they do in advocacy and education.