Concussion in Sport

Concussions in Sports: Part 1 – Risk and Recovery Process

Concussion in SportConcussions in sports are becoming more and more of a problem as our athletes continue to get bigger, stronger, and faster.  As our understanding of the impact of concussions continues to increase, the need for knowledge of how to manage and rehabilitate athlete’s with concussion becomes paramount.

Today’s guest post discusses Concussions in Sports from Shaun Logan, DPT.  This is part 1 of a 2 part series on Concussions in Sports that will give a brief overview of concussions and the recovery process.  This information is needed before we can even discuss how we can best manage these injuries.  (Photo from Wikipedia)

Part 2 will specifically discuss the role of physical therapy in concussion management.  If you are interested in learning more about concussions in sports, read my past article on the evaluation and treatment of concussions that includes a nice link to a Journal of Athletic Training consensus statement.

Concussions in Sports

Between 1.4 and 3.6 million sports and recreation-related concussions occur each year, with the majority happening at the high school level.[1] Studies estimate 10-19 percent of all athletes involved in contact sport sustain a concussion each season.[2] As concussions have become more prevalent in the every day media, with more research being conducted and information discovered every day, the role of rehab and physical therapy for concussions has been emerging.  This is something that has been discussed and practiced by few for several years, but is still relatively new to most clinicians.

Concussions in Sport

In the 3rd International conference on Concussion in Sport in Zurich (2009), McCory et al. defines concussion as, “A complex pathological process affecting the brain, induced by traumatic biomechanical forces.”  In general terms, a concussion is an injury to the brain that occurs when a force is transmitted to the head that causes the brain to “shake” inside of the skull resulting in injury.  This can be a direct hit to the head, face, or neck – or can be caused by a force applied elsewhere on the body that is then transmitted into the head. [3] Helmets were not made to prevent concussions, as they are unable to prevent the brain from shaking in the skull. Helmets were made to prevent skull fractures and blood vessel injury. [4]

Recovery from Concussion

Headaches, fogginess, confusion, and disorientation are among the most common symptoms of concussion in the first week. [4]  Generally, most concussive symptoms will subside within 7-10 days without any treatment other than rest. [1][3][4]  Therefore, most athletes completely recover within that 7-10 day time period. However, concussed athletes still need to be progressed properly and continually assessed for any symptoms that may arise with increased movement, activity, or exertion.

The accepted best practice for concussion management, recovery and eventual return to play is for the athlete to be on complete rest both physically and cognitively until symptoms are no longer worsening.  Cognitive, or mental, rest includes, but is not limited to, not participating in the following activities: watching TV, texting, reading, going to school, and being in loud crowded places. This rest period can take anywhere from a few hours to days or weeks, depending on the severity and symptoms of the concussion.

Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases. [2] This is what is known as Second Impact Syndrome.  In documented cases, when a second brain injury occurs within 3 weeks of the initial concussion (most commonly within 7-10 days) there is some form of permanent brain damage in 100% of cases, with 50% resulting in mortality. [4] (There is a small sample size of documented cases, but this is still an astounding result)

Post-Concussion Syndrome

Not all concussed athletes will completely recover in the 7-10 days.  Studies show only about 10% of athletes show symptoms beyond 1 week and 1-5% with symptoms for longer than a month.  The prevalence of extended symptoms for high school athletes was about double that of college athletes.  These are the athletes who require rehabilitation. [4]

Athletes who continue with signs and symptoms for more than 3 weeks are considered as having Post-Concussion Syndrome (PCS). Though there is not a concrete agreed upon definition of PCS, the World Health Organization defines PCS as: “Three or more of the following symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, or memory difficulty experienced for weeks, months, or occasionally years after a concussion”. Other symptoms would include photophobia, tinnitus (ringing in ears), visual, and balance problems. [4]

The athlete must be appropriately monitored and progressed through activities by a health care profession, such as a physical therapist or athletic trainer, to prevent mismanagement of the concussion. Mismanaging a concussion is associated with several risks. [4]

Short-term risks of mismanaging concussion include:

  • Persistence or worsening of post concussion signs and symptoms
  • Repeat concussion with post-concussion syndrome
  • Second impact syndrome

Long term Risks of mismanaging concussion include:

  • Prolonged post-concussion syndrome
  • Depression, cognitive impairment, Chronic Traumatic Encephalopathy

Rehabilitation and the Concussed Athlete

Current thought is once the concussed athlete is asymptomatic at rest the physical therapist and athletic trainer’s role emerges in the form of a graded program of exertion, which will be discussed later in part 2. This is true, but it is only part of what we are able to do to aid in recovery and progress towards safe return to sport.

Read on to part 2 regarding the rehabilitation following concussions in athletes.



  1. University of Pittsburg Medical Center. (2011)
  2. University of Pittsburg Medical Center. (2011)
  3. McCory P, Meeuwisse W, Johnston K, et al. (2009) Consensus Statement on Concussion in Sport: the 3rd International Conference on Concusion in Sport held in Zurich, November 2008. Br J Sports Med; 43: i76-i84
  4. Guskiewicz, K. Concussion and Postconcussive Syndrome: When to Rest, Exercise, or Return to Sport. 2010. APTA Annual Meeting, Boston, MA
  5. Wallace, B. (2011) Concussion Health: Program
  6. Mucha, A. Physical Therapist’s Guide to Concussion. American Physical Therapy Association. 3/24/2011
  7. Wallace, B. Concussion Management Guidelines: Balance 360. By Concussion Health. (2011)

 About the Author

Shaun LoganShaun Logan, DPT practices out of The Training Room: Sports and Orthopeadic Physical Therapy located within Velocity Sports Performance in Cherry Hill and Washington Township in South Jersey where he has recently started a concussion program. Shaun graduated from Penn State University with Bachelor of Science degree in Kinesiology: Movement Science and from Drexel University’s DPT program in 2010. When his schedule allows, he returns to Drexel University to assist in teaching orthopedics. Shaun is working towards becoming board certified in sports.

7 replies
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  3. concussion therapy
    concussion therapy says:

    Thanks for a great post Shaun. I’ve been writing about concussion for a while and it’s great that you also did. Post-Concussion Syndrome (PCS) if it is recurring could be a very dangerous sign.

  4. Lauren
    Lauren says:

    Great article Shaun! As an PT/ATC, I have been progressively more interested in moving into concussion rehab. Looking forward to your next post. Do you have any specific concussion CEUs you would recommend? Or more just straight forward vestib? Thanks!

    • Shaun
      Shaun says:

      Thanks Lauren! I don’t have any specific concussion CEU’s I would recommend right now. If you are an APTA member I would recommend checking out a lecture by Guskiewicz, which is from 2010 but has good info (it’s D under the references).

      There was also a course at this past CSM by the people at UMPC, who always seem to be at the forefront of concussion management. It is “The role of the PT in the Evaluation and Management of Athletes following Sports Concussion” – Michael Collings, Dana Hinderliter, Anne Mucha, and Susan Whitney. They weighed heavily on the evaluation aspect but it’s good.

      Anything you see with anyone from UMPC or Guskiewicz will likely be good. I haven’t found any vestibular courses that I have been interested in but I keep looking. I’d also recommend shadowing a doctor who see’s a high volume of pt’s with concussions, just to see how the pt’s present with a wide range of symptoms, get to see the physician’s evaluation, and you can discuss with them as well. Hope that helps a little!

      • Meghan
        Meghan says:

        There is new research coming out sometime this fall from Dr. Esty at the Brain Wellness and Biofeedback Center of Washington later this year (not sure which publication, but can find out). The research is on various EEG Biofeedback training and concussions… particularly the Slow-to Recover/PCS patients. Pretty interesting stuff which is gaining more popularity for elite athletes. For those small percentage of patients who have long-term effects, it might be a good supplement to traditional rehab and vestibular rehab.

        Just something to think about since the media craze tends to push patients to jump on the “latest and greatest” like the PRP treatments for joint injuries!

        Also, in regards to the vestibular rehab, I know the folks at Dr. Crutchfield’s office at Sanai and other “concussion experts” have been heavily recommending Wii Balance as part of their rehab. I have seen clinical success with this, yet have been unable to find worthy research on the topic.

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