"Committed to Educate, Not Just Rehabilitate"

"For Whom Does the Bell Toll ?"

Having your "Bell Rung" has much greater meaning today than it did twenty and thirty years ago. Having your "Bell Rung" refers to having had a Concussion, in medical terms. This sports injury is significant to the point of interfering with an athlete’s season, or even worse, ending his/her career. An injury of this type should never be taken lightly.

The definition of Concussion is a very controversial topic in Sports Medicine as there are many different opinions of what the definition should be. The most widely accepted definition comes from the American Academy of Neurology (AAN). Concussions are graded as first, second, and third degree. A loss of consciousness only occurs at the third degree stage. A Grade I Concussion is defined as a transient disturbance of mental status function, which lasts less than 15 minutes. A Grade II Concussion is defined as a disturbance of mental function which is more severe in nature. These disturbances may include either a Post-Traumatic Retrograde (back in time) or Antegrade (forward in time) amnesia, diminished ability to concentrate, and a decreased ability to perform basic cognitive functional tests (do simple arithmetic/memorize/learn new information). These disturbances will last longer than 15 minutes with no definite termination of symptoms. As mentioned, a Grade III Concussion includes the above with a loss of consciousness.

A Concussion occurs when there has been either a direct or indirect blow to the head. People do not realize that an injury can occur to the brain, even though there has not been any direct impact to the head. The concern about having repeated Concussions is that the negative effects are accumulative and this is why it is vital to keep the athlete out of any sport (not just his/her sport) that potentially can cause a further insult to the brain. If another injury to the brain occurs before the prior one has fully recovered, the acute condition of the Second Impact Syndrome (SIS) can occur. This phenomenon occurs when an athlete receives a fatal injury to the brain before it has time to fully recover from the previous injury. The ultimate effect is that the brain swells very quickly producing a rapid decline in overall brain function ending in death of the athlete. This premature return to sport has the ultimate penalty of life, which is DEATH ! Nobody ever wants to receive this penalty.

The way to avoid a premature return to sport is to follow a logical protocol of physical and psychological testing that can occur to give an athlete medical clearance. With a Grade I Concussion, simple testing on the sideline may be sufficient with a set of mental status questioning and having the athlete exert him/herself physically on the sideline. If there are no further symptoms of headaches, dizziness, nausea, blurred vision, the feeling of being a "step behind your body", unusual fatigue, and/or a "grogginess", then the athlete may return to the field with a constant monitoring of the symptoms. If there is the slightest suspicion of ongoing symptoms, then pull the athlete and retest him/her the next day. In the case of a Grade II Concussion, the athlete will be removed from the field and enter into a stepwise protocol to follow before returning to the field. A Sports Medicine practitioner should be sought out for consultation before returning to the sport ! The bottom line is that an athlete should not return to the field of play of any sport until he/she is ASYMPTOMATIC (without symptoms).

If an athlete experiences repeat concussions within the same season, then the medical staff should lengthen the amount of time the athlete should be asymptomatic before returning to competition. You can never keep an athlete out too long, but you sure can put him/her back in too soon. "When in doubt keep the athlete out". Once the athlete is asymptomatic for at least 24 hours following a Grade II/III Concussion, he/she may enter into a five-stage protocol, which begins with a 10-minute stationary cycle ride, with the heart rate < 120 bpm, and ends with the final return to practices/games. This return only occurs if the athlete is asymptomatic throughout the testing period and following into the next day.

For the most part, concussions are handled reasonably well, but there is very little margin for error. As mentioned, "when in doubt, keep the athlete out", and seek the proper medical attention. Sport is meant to be fun first, and there is nothing fun about dealing with a concussion. This issue is very relevant for coaches, parents, and teammates alike.

Be smart, use your brain to perform your sport, don’t let your sport use your brain ! Remember, don’t let the "bell toll" for you.

Respectfully submitted,


Howard A. Winston
MD, CCFP, FCFP
Dip. Sport Med. (CASM)
Medical Director, The Centre for Health & Sports Medicine