When in Doubt, Sit Out

As Far as Leading Concussion Experts are Concerned, Return-to-Play Guidelines are Cut and Dried

Never trust a cheerleader. Or an athlete. While we’re at it, parents can’t always be counted on to do the right thing when a game or season is on the line. 

No matter what the sport, when it comes to dealing with concussions, honesty is the best policy, but injured athletes don’t always tell the truth. Not when victory is hanging in the balance or there’s a big game creeping up on the schedule. Athletes will say, and do, whatever it takes to keep on playing, even if that means putting themselves at risk for greater injury.

Mark Lovell has been on the frontlines of the concussion battle for more than 25 years. His message to athletes, coaches and parents is very simple: when in doubt, sit them out. It could be the difference between life and death.

“If you think the athlete has suffered a concussion, they probably have,” said Lovell, the founding director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program.

“Athletes often deny symptoms, so you can’t believe them because they will say whatever they think you want to hear to get back on the ice.”

Or the basketball court, practice field or cheering from the sidelines.

Signs and Symptoms of Concussions


• Appears dazed or stunned
• Is confused about assignment
or position
• Forgets an instruction
• Is unsure of game, score or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior or
personality changes
• Can’t recall events prior to
the hit or fall
• Can’t recall events after hit or fall


• Headache or ‘pressure’ in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish, hazy, foggy or groggy
• Concentration or memory problems
• Confusion
• Just not ‘feeling right’ or is ‘feeling down’
• Taken from the Centers For •

Disease Control Concussion Web site

Over his career of working with the Pittsburgh Steelers, Lovell has stared down NFL linemen and linebackers when delivering the bad news that they would not return to the field of play until their concussion symptoms had cleared up. But even those towering hulks of testosterone could barely match the ferocity of a hockey mom who has been told her son would not be allowed to return to the ice until his symptoms have cleared up.

“Sometimes their parents are the hardest to deal with because they don’t understand the seriousness of the injury,” said Lovell, whose work in the field of concussions earned him the 2010 USA Hockey Excellence in Safety Award.

“I have definitely had some situations that can be categorized as being a little uncomfortable.”

While it may seem rash to pull a star player from a big game because he or she may have suffered a concussion, think of the alternative. A second blow to the head can be serious, since repeated concussions can cause cumulative damage, and the severity of the trauma increases with each incident.

It’s not that any parent wants to put a son or daughter in danger, Lovell said. It’s just that they may not understand the long-term health issues far outweigh the short-term disappointment of missing a game, a week or even a season.

Education is the key. That’s why the medical and hockey communities came together in mid-October at the Mayo Clinic in Rochester, Minn., for a two-day summit on concussions in ice hockey. The program covered topics ranging from the short and long-term effects of head trauma on the brain to concussion prevention techniques to reducing aggressive behavior in youth hockey.

In the end, the group created a series of action plans in the hope of curtailing the risk of concussions while raising awareness of the severity of the problem.

“Now that the summit is over, the real work begins,” said Dr. Michael Stuart, USA Hockey’s chief medical officer and one of the organizers of the summit. “We need to take this message to all the groups within hockey because each of us is a stakeholder in the safety of our game.”

The number of reported concussions is on the rise, particularly in youth sports. But according to Lovell and other neurologists who are on the front lines, it’s not because there are more concussions but rather the methods of diagnosing and responding to the early warning signs have dramatically improved over the years. No longer do coaches chuckle when they talk about their players “having their bell rung” or “seeing stars” after a big hit.

As important as reversing those trends has been, it’s equally important to follow established return-to-play guidelines, which start with coaches recognizing the signs and symptoms and keeping players off the ice until they are eventually cleared to play by a physician. 

The course of treatment depends on the patient’s age, concussion history, symptoms, signs and type of sport. It is recommended that all concussed athletes be cleared for return to play only after consulting with a physician.

And each case is different. One player may be cleared to play in a week while another is forced to deal with symptoms throughout the season or even longer.

“One of the fundamental principles that we all need to understand is that concussion management and return-to-play guidelines are individualized. There is no cookbook approach,” said Stuart, who has two sons currently playing pro hockey.

 “What I tell players, parents and coaches is that return to play after a concussion varies from one week to never. That’s because a symptomatic athlete can never return to play.”
That can be a tough pill to swallow for an athlete in the prime of his or her life. But missing the rest of a game or the rest of the season is a small price to pay compared to the long-term effects of a second concussion.

For doctors who have spent their lives dealing with concussions, the time has come to change the mindset that standing on the sidelines is somehow a sign of weakness, or that players are somehow letting their teammates and coaches down as they convalesce.

“I am happy to say,” said Robert Cantu, an expert in the field of brain trauma at Boston University, “that we will never return to the day when a child is knocked out of a game and is brought back in and is cheered for his toughness.”




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