Concussion and youth athletes
How can your club support young athletes who experience concussion during training and competition.
Concussion attracts a healthy amount of discussion and controversy in professional sport. Whilst the risk of concussion has not been eliminated by recent rule changes to contact sports, the safeguards that exist for professional athletes post injury are as good as they have ever been. Football (Soccer) clubs have a host of medical professionals positioned on the sideline to attend to suspected concussions. In Rugby League there is an independent doctor with access to video replays and the ability to remove an athlete from the field of play following an impact to head or neck if it was missed by the club’s own staff.
Similar support is rarely available in youth sport making the task of recognising and managing concussion more difficult. Such is the concern that governing bodies have published guidelines on how clubs can identify and manage suspected cases of concussion. The UK government released their concussion guidelines for non-elite (grassroots) sport in 2023, titled ‘If in doubt, sit them out’. The Australian sports commission followed suit in 2024 with concussion guidelines for youth and community sport. Links to both are at the foot of this article.Â
The documents provide clear guidelines and support for those involved in youth sport who might encounter instances of concussion. Despite this the provision at most youth sport events, particularly training, falls short of what is proposed. So, how can clubs better use these new guidelines to support their members using the resources available?
Recognising concussion
Youth sport is unlikely to have the benefit of video replays nor independent doctors which presents a problem in detecting a potential concussion. Coaches are, well, coaching and so their attention is usually focused on where the ball is. The signs and symptoms of concussion often manifest after a collision when the ball and play have moved on. Health care professionals are trained to not watch the ball but focus on how players recover after contact to identify potential injuries, including concussion. Few youth sports will have this type of sideline support, especially at training. This results in uncertainty regarding whose responsibility it is to spot the symptoms of concussion, a task made more difficult as athletes get older and the playing area becomes bigger with a greater distance between club staff and the athletes.Â
Clubs can navigate this challenge by asking parents or volunteers to act as a ‘concussion officer’, something suggested in the Australian Sports Commission guidelines. The concussion officer is tasked with observing the match or training session to identify instances where they believe a player should, as a result of contact to the head or neck, be removed from the field of play. The guidelines on concussion are very clear on this. In instances where a suspected concussion has occurred, the athlete should be immediately removed from the field of play and have no further involvement. As such, it is crucial that coaches and other parents understand the role of the concussion officer and respect their decision to remove an athlete from the field when deemed necessary. To navigate this challenge clubs may elect to share the responsibility of being the concussion officer between parents over the course of a season. This means that everyone is responsible for recognising potential concussions, receives an appropriate level of education on the issue and, where multiple games or sessions are taking place simultaneously, can provide adequate coverage. We do this for scoring, BBQ duty and half-time snacks so why not concussion?
Signs and symptoms
Few of us involved in youth sport have medical training and so tools have been developed to help recognise and manage concussion. The most widely used is the concussion recognition tool 6, or CRT6 citied by the British Journal of Sports Medicine and by both the Australian and UK concussion guideline documents. A link to the tool is included at the foot of this article. Tools exist for both adults and adolescents.
The CRT6 details a range of symptoms associated with concussion that parents, coaches and, importantly, the concussion officer can look out for. Some of the more serious signs you will already be familiar with, such as a loss of consciousness, however others are more subtle. They include, visual or hearing disturbances, changes in balance, sensitivity to light, feeling like you are 'in a fog’, and disorientation. Recall the title of the UK document, ‘if in doubt, sit them out’; if you are unsure, err on the side of caution, remove the individual from the field of play and do not allow them to return. This means that your concussion officer or parent should be empowered by the club to stop play and remove a child if they are concerned, without any negative reprisals or repercussions from others.
Coaches (and parents) can be a challenge here, especially if there are limited substitutes to take the place of the athlete taken from the field or, if they are deemed to be an important part of the team’s success. It is important that your club, at an organisational level, ensures coaching staff understand the concussion rules at the start of the year so that no undue pressure is placed on those tasked with protecting the players. This might be part of the introduction pack given out at the start of the year or form part of the briefing session prepared by the club for coaches and parents, particularly where the latter are volunteers. I wonder how many clubs and national governing bodies share the guidelines with their coaches as part of a briefing session or with parents and guardians when they register at the start of each new season?
Once the athlete has been removed from the field the CRT6 identifies red flags which, if present, should result in the athlete being referred to an emergency department. These include neck pain, repeated vomiting, severe or increasing headache (for a full list, refer to the CRT6). Again, for training particularly, there is unlikely to be a health care professional in attendance and so the responsibility falls on the club, coach and anyone else in attendance to ensure appropriate medical attention is called for. This may include taking the athlete to hospital, calling an ambulance, calling parents or guardians so they understand the need to seek medical help or, where the athlete is of driving age, arranging for someone to collect their car whilst the athlete is at hospital. Driving is not recommended for anyone suspected of having suffered a concussion. Clubs can prepare for this eventuality by having a designated person each week whose responsibility it is to accompany an athlete to hospital if no family members are present or to wait with them whilst they are picked up. This may seem obvious for younger athletes however for older athletes who have travelled independently it is important that they are not left alone and someone from the club accompanies them until a parent or guardian arrives.
Information sharing
Whoever is given the responsibility of recognising concussion should also be asked to note down how the incident happened along with any associated signs and symptoms observed. These details will need to be relayed to the child’s parents or guardians so that they can inform medical staff if a hospital visit is required, to relay to medical professionals at later date if symptoms persist, and for assisting the club to manage the return to play. The CRT6 forms provide a template for collecting the necessary data; physical copies of which should be available at each training session and match.Â
Parents and guardians also have a role to play. They should ensure the club and coach has up to date contact information if they are not attending training or matches with their children. When children reach the age where they can travel independently, it is important clubs retain the ability to inform parents that follow up medical attention should be sought.Â
The above should prompt clubs to review their processes for managing all types of injury sustained during training and match play. Aside from the acute response to serious injury which most will handle with the assistance of paramedics, there are a range of issues which might require follow up medical attention and the sharing of information with parents and guardians who may or may not be in attendance. Further, clubs may also want to consider how they ask athletes and parents to share information with them. For example, when a youth athlete plays two or more sports, the club may want to know from parents if they have suffered a concussion in a different activity so that training and exposure to competition can be managed appropriately. In an age with seemingly unlimited modes of communication, the excuse of ‘we didn’t know’ no longer holds muster.
Return to play guidelines
One of the most challenging components of managing concussion is the process of return to play. Following a suspected concussion, youth athletes should take an initial period of 24-48 hours rest. This should include complete rest or very light physical activity (gentle walking), no screen time and mental tasks such as reading and/or learning should be limited to short, 15 min blocks. This period presents a number of challenges. Firstly, clubs need to ensure parents and guardians understand the importance of this acute period, which is likely to necessitate 1-2 days off school. Secondly, parents and guardians need to understand that although symptoms may appear to be minor, and whilst two days off school is likely to present challenges to their weekly routine (I speak from experience), that it is a vital part of recovery.Â
After the initial 48 hours, learning and work activities can be reintroduced along with some light physical activity albeit for short periods. The UK guidelines suggest that in the first week of recovery schoolwork is introduced at home so that symptoms can be monitored with learning activities limited to 20-30 minute blocks. Post concussion, prolonged mental tasks or vigorous exercise can exacerbate symptoms if introduced too early. The guidelines propose that attendance at school be reintroduced in a part time nature at first. Such an approach will require the input of the school, parents and club to ensure the athlete is able to recover in the most appropriate manner. Clubs may seek an audience with school principals and associated parent and carer committees to highlight practical strategies that support the recovery of youth athletes without compromising their education.Â
Youth athletes should be symptom free for at least 14 days before they resume training that involves physical contact or collisions, this would include, for Football (Soccer) as an example, heading the ball. Competitive sport should not be reintroduced until 21 days after the athlete is symptom free. This is an important distinction, it is 21 days after the athlete is symptom free and not from when the concussion occurred.Â
This is where clubs need practical strategies to ensure athletes recovering from a concussion do not lose contact with their peers. Firstly, the club may, through communicating session plans in advance, allow athletes to take part in low intensity activities with the rest of the squad. This might include passing drills, stretching or technical drills where there is no risk of contact or collision. Sharing session plans in advance lets the youth athlete know which sessions they are can participate in safely allowing them to more effectively plan their week. Clubs who are selective in nature should work to ensure that athletes who cannot train or compete feel supported and part of the squad. Athletes and their parents who feel an extended period on the sideline puts their place on the team in jeopardy, may be more likely to under report symptoms and get back to training and competition quicker than is medically appropriate. This is especially pertinent for injuries like concussion where, to the uneducated, the symptoms are less visible and considered trivial. Clubs also have a responsibility to not select athletes for a minimum of 21 days after a concussion has occurred and preferably, with effective communication with parents and guardians, not before 21 days after the athlete is symptom free.
This article is not intended to replicate the information in the concussion guidelines for youth sport. It is intended to highlight the practical steps clubs can take to manage this type of injury in the acute and chronic stages of recovery whilst identifying some of the challenges and practical solutions.Â
Successful management of concussion in youth sport requires collaboration between clubs, coaches, parents and guardians and schools. This is no easy task however, as our understanding of concussion grows, clubs need to ensure that athletes and parents are confident in the processes in place to protect their wellbeing. If they are not, participation in sports characterised by collisions and physical contact is likely to suffer.
If in doubt, sit them outÂ
https://sramedia.s3.amazonaws.com/media/documents/9ced1e1a-5d3b-4871-9209-bff4b2575b46.pdf
The Australian Sports Commission youth sport concussion guidelines
Concussion recognition tool 6