Understanding the 5 stages of concussion protocol

2014-12-18 09:32:38 by Dr. Joe Congeni - Director of Sports Medicine, as posted on the inside.akronchildrens.org blog.

Cleveland Cavaliers forward Mike Miller was placed on the NBA's concussion protocol. He was started having concussion-like symptoms after being unintentionally struck in the head during a game. Cleveland Cavaliers forward Mike Miller was placed on the NBA's concussion protocol. He started having concussion-like symptoms after being unintentionally struck in the head during a game.

With many uncertainties centered around when Cleveland Cavs' Mike Miller and Cleveland Browns' Jordan Cameron will return to their respective games, I wanted to discuss the specifics of concussion protocol.

Many people confuse the protocol's 5 stages with 5 days. And that's just not the case. It varies by player and the severity of his concussion, as well as the number of concussions he's experienced. It could take anywhere from a week to a couple of months for an athlete to advance through all 5 stages and get back on the field.

Yesterday, I had the chance to visit in studio WAKR morning show host Ray Horner to discuss this topic. We talked about the 5 stages of concussion protocol and how players advance through what trainers call the "buffer zone."

Below is an audio file and transcript of our discussion. Originally aired on 1590 WAKR-A M on Dec. 17, 2014.

HORNER: In our studio right now a guy who knows sports a little bit, from a different angle, and that's Dr. Joe Congeni with us from Sports Medicine Center at Akron Children's Hospital. That word concussion is front and center again, isn't it, Joe?

DR. CONGENI: You know the word concussion protocol, concussion protocol, protocol, protocol?


DR. CONGENI: Everybody kinda wonders what is this protocol? And, you know, it's supposed to be the same from youth to high school to college. It's a little bit different, being honest about it, but I wanted people to try to understand what the protocol means; what it's supposed to mean.

Of course, you know, we don't know what's going on with somebody Jordan Cameron (of the Cleveland Browns), you know, Mike Miller (of the Cleveland Cavaliers). Why do some take longer? Why are some guys back within, you know, a week of the game and all that kind of stuff? ...

HORNER: Yeah, some guys are out 6 weeks.

Dr. Joe Congeni Dr. Joe Congeni

DR. CONGENI: Yeah, 6 weeks or more. So, the deal with the protocol, Ray, the way it works -- and with the new state law that we passed ... it goes all the way down to youth -- is there are 5 stages of the protocol.

And, before you even get into the protocol, you have to be symptom free. So, you have to have recovered from the concussion. You have to pass some of those concussion tests. We won't get into what they are today, but a couple of concussion tests.

Then, when you do all that, there's a period, some of the trainers call it a buffer period, before you go back. You don't just play right away.

So, you start with 5 stages. A lot of people are confused it's 5 days. No, it's not 5 days. Some people take 2 days for a stage or 1 day, minimum a day for a stage. Some people take a week per stage.

So, the first stage is you go out and you run and work out and do an aerobic exercise on your own.

And the second stage, you do a sport-related activity. So, if it's soccer, you dribble the ball, pass the ball on your own, uh, shoot. The things you'd have to do for your sport.

The third stage, you practice, but non-contact. You wear a yellow jersey or a red jersey. Practice with the team without having any contact.

The fourth stage is a full contact practice.

And, stage 5 is full play in a game.

So, when they're talking about the protocol, they're talking about those 5 stages that the trainers know as the "buffer zone." So, you don't go right from clearing up with the concussion to playing the game tomorrow.

And, some of those stages, every one, Ray, if you go back to stage 3 and you start practicing and you get dizzy, light-headed, uh ...

HORNER: You go back to one?

DR. CONGENI: You go back to one.

HORNER: Hmm-mmm.

DR. CONGENI: So, you don't know where Mike Miller is. ... They told you, "Hey, he practiced yesterday."

HORNER: Right.

DR. CONGENI: If he practiced and he comes home and he has symptoms and things like that, you know, he's going back and starting over again on the protocol. So, you can't predict these things and that frustrates fans, doesn't it?

HORNER: Joe, you opened it up by the concussion tests and then you get into protocol. Tests? Are these written; are these moving; are these thinking tests; all of the above?

Browns Pro Bowl tight end Jordan Cameron has been following the NFL's protocol on head injuries after getting his third concussion in three seasons. Browns Pro Bowl tight end Jordan Cameron has been following the NFL's protocol on head injuries after getting his third concussion in three seasons.

DR. CONGENI:  Well, different doctors that evaluate people for concussion can use different types of testing. Some people just use clinical tests that they do on a patient in the office.

Many, many people now use the computerized tests that really test your thinking. They test like reaction time. How quick is your reaction time? They test problem solving. They test memory.

They do it in a way so that it is on the computer and you can compare them to either themselves, if they had a baseline, or you compare them to what other people their age should be getting. So, that's one of the tests. It's called a cognitive test.

Now, there are some tests now, there are balance tests, where you test balance. There are some tests that are performance tests, where they actually test you before the season, (i.e.) how quickly you change directions and how you get your heart rate up and things like that. And then after the concussion, you do a performance test again.

So, there are a lot of different tests and it's up to the people that are doing the evaluation. And, you know, in the pros, it's supposed to be an independent neurologist who puts them through the tests.

But, as you're passing the tests, then the doctor can say, "Okay, we're ready now for the protocol, stage 1. You're ready for stage 2 or stage 3."

It's not the same for every person. You know, people want it to be, uh, a cookbook and it's not. It's different individually.

HORNER: Does the protocol change from sport to sport?

DR. CONGENI:  The protocol's really the same from sport to sport. Yes, it's not different. Well, you know, like I said, sport specific. So, for football day 2 and practice day 3 would be a little bit different.

HORNER: Right.

DR. CONGENI:  ... But, no, the protocol, the length of the protocol, the 5 stages is the same for a youth kid playing football and, you know, an NBA player playing basketball.

HORNER: So, if you see a player, for example, who hasn't passed all 5, let's say his next game is Friday, by Wednesday, he's not gonna play Friday.

DR. CONGENI:  For sure.

HORNER: Looking at everything the way that stacks up, right?.

DR. CONGENI: Yeah, yeah. So, they ask and they try to pin down David Blatt (Cleveland Cavaliers head coach) or all these different people ...


DR. CONGENI: ... and they don't know either because the one unpredictable thing is, okay, you know Mike Miller's on stage 4, but oh, Mike Miller became symptomatic ... and he's not doing well and goes back, you know, stage 1 or stage 2 or something like that.

So, it's very, very unpredictable and that's difficult for fans and coaches.

HORNER: Dr. Joe Congeni with us in studio. Joe, does that change if you've had multiple concussions? Does the playing field change in regards to protocol and testing?

DR. CONGENI: Well, what changes it is the people doing the evaluation. That's a great question, Ray. You know I always tell ya how good you are at understanding.


DR. CONGENI: You really are. That's a deeply, thought-out question.

Sure because the reason is the person doing the evaluation. Like us, you know, as the sports medicine docs, we know typically if you've had even one concussion, you take twice as long to recover as people that have never had one before.

So, you may make the stages 3 days or a week or a longer period of time, you know. You're kinda projecting what it would be, but you say, "I want that person in stage 2 for, you know, 3 days or maybe even a full week of stage 2 before they go to the next stage," because they've had concussions before.

A place that was probably evident -- again, I don't see these guys, but reading between the lines -- was Jordan Cameron had had a couple. And you read between the lines that they were taking it very slow with him. So, the stages for him were probably slower and they adjusted it individually for the fact that, what did they say he's had, 3 or 4?

HORNER: Yeah. I bring this up because I know a middle-grade student who's had 3 concussions.


HORNER: And, they haven't had the medical evaluation, but his parents have said, "Hey, let's hold back on activities," and that type of thing. Matter of fact, he got the last concussion by being hit in the head with a school textbook by accident.

If you get 3 concussions like that before the age of 15, at what point do you bring in a medical professional and look and see if this person should stay out, or is this a case-by-case thing?

DR. CONGENI: Good question, too. I don't want to be ...

HORNER: You're not going to set that number.

DR. CONGENI: If you're a student and you're rushing to, you know, get back to a sport and you want to know when can I play again, you really need to see a medical professional for that.

But, for a lot of things, if you're not in a contact sport, just rest and giving it time to settle down is probably not an unreasonable step because you're not hurrying back, so you don't have to go through a concussion protocol or anything like that.

But, after you've had 2 or 3, what worries me about that story you just told me ... is the third time it doesn't take very much. We hear this a lot. Somebody opened their locker into my head. ...

HORNER: It's what happened.

DR. CONGENI: You know, somebody just hit the book across the top of my kid's head and it's their third one. You know, now it's not taking much trauma to induce .

That would be one where I would see a concussion-related expert to kinda talk about specifics of what should be done and evaluating that kid.

Do you see what I'm saying?


DR. CONGENI: If it's a first one and it's not an athlete, there's no rush off to be in a concussion protocol. Does that make sense?

HORNER: Yeah, it does. Dr. Joe Congeni with us in studio, Sports Medicine Center, Akron Children's Hospital. Good visit with us, my friend.

DR. CONGENI: Thanks so much, Ray.

HORNER: Good meeting your wife back there. She took you in live in the studio today.

DR. CONGENI: Twenty years and she finally came over with me. Thanks, Ray.

HORNER: Well, we're gonna have to get her in here more . Next time, bring the whole crew in over the holidays. Are they all coming in, by the way?

DR. CONGENI:  Yeah. We'll have all six of 'em in here with us. Yeah, thanks, Ray.

HORNER: Very good. Have a good holiday.

DR. CONGENI: Thanks. You too.

HORNER: There you go. Dr. Joe Congeni, Sports Medicine Center, Akron Children's Hospital, with us.

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