Sports specific recovery from Concussion

blurry hockey
Body checking starts at age 11 in most sanctioned ice hockey programs  PHOTO: Mike Sefton
October 9, 2018 Cognitive and emotional symptoms often occur when an athlete sustains a concussion. Individual sports have somewhat different trajectories when it comes to recovery – sometimes because of the nature of the sport and sometimes unique to the athlete and his or her emotional predisposition. Ice hockey is a high speed collision sport. Many athletes play the game on a year round basis chasing a dream of collegiate or professional status. Ice hockey has a high degree of collision-related concussions according to the National Council on Youth Sports.
Contrary to current beliefs, even currently healthy youth hockey players reported higher persisting psychological symptoms among those with a history of concussion. Psychological sequelae appeared unique to a history of concussion as athletes with a history of musculoskeletal injuries did not present with the same persisting psychological symptoms. A study in Pittsburgh looked at the incidence of concussion among younger and older adolescent players from elite hockey programs.  They found a higher rate of concussion among younger players.  In a post last month I presented the notion that size matters when it comes to elite (younger) athletes playing against older and more physically developed athletes.  Concussions tend to be both more frequent and more long lasting.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up against older and more developed players. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the shear difference in size and strength.  Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are athletic failures and weak unless they play through their injuries – including concussion according to Sefton, 2018.
In 2016 the majority college ice hockey player spend one to two years in junior hockey (ages 17-21) allowing them to continue their physical development prior to entering college hockey.  This includes not only Division I scholarship programs but Division II and Division III programs as well.  Very few natural freshmen play college hockey at 18 years of age unless they are highly gifted athletes. Even these players are coached and managed by trainers with ongoing development programs, weight training, and nutritional support to enhance upper body size and strength.    Michael Sefton, 2016
Even though sport concussion is considered a unique subset of MTBI, results suggest that a smaller percentage of youth may be more prone to psychological sequelae following concussion. This means that not all concussions are created equal. Along with colleagues across the country I have been saying this for over 20 years. There is a literature on elite ice hockey players and a co-occurring mood disorder that needs to be addressed as they heal.
When I first started taking an interest in MTBI, also called concussion, physicians did not believe that someone sustained a brain injury unless there was a bonafide loss of consciousness. This remains one of the greatest myths in brain injury rehabilitation and I still hear from people that a son or daughter has a concussion “but he did not get knocked out” as if that minimizes the significance of the injury they sustained. Finally, I am still getting significant push back from the parents of children who are diagnosed with multiple concussions. The recovery from concussion two or three is not the same trajectory as the first. Many wonder why their child hasn’t bounced back like they did the first time around. And common to second concussion irritability and other mood-related changes are common.
I suggest to parents expect the unexpected and try not to attribute changes in school functioning to laziness alone. Plan on working with the school-based support team and athletic trainer as you return to learn and return to play.  Most elite programs offer emotional support for athletes suffering with the effects of concussion. Many feel isolated or marginalized because they may appear normal and walk and talk just like other members of the team. Athletes recovering from concussion are at higher risk of second concussion if they return to play before their injuries heal.  This takes 7-21 days on average.
The Pittsburgh study, published in Pediatrics in 2016, revealed that the population of ice hockey players they studied had a higher preponderance of players who had sustained one or more concussions.  This is what I experienced in looking at junior level ice hockey (typically aged 16-20 years) teams a few years ago.  I was surprised when I asked how many had sustained a prior concussion and most all the players raised their hands. Fighting is first allowed in this level of play and sometimes becomes a handicap for players with sites set on collegiate play.  In many cities across the country junior hockey is the only show in town.  Some cities in the mid-west actually televise games and report scores on local sports programs.
Remember no two concussions are the same. Sports all have their return to play protocol that begins with recognizing the importance of controlled exertion in the setting of concussion and recovery.

Sefton, M. (2016). Body Checking in Hockey: When size matters. Blog post: Taken October 9, 2018

National Council on Youth Sports
. Report on trends and participation in organized youth sports. Available at: Published 2008. Accessed March 17, 2015


Kontos, A. (2016) Incidence of Concussionin Youth Hockey Players PEDIATRICS Volume 137, number 2 , February 2016 :e 20151633 Taken October 9, 2018

Return to school: Psychologists also working in the trenches after concussion

WESTBOROUGH, MA May 1, 2017 The return to school following a brain injury should be carefully planned.  School nurses tend to be the point person for parents’ whose children are coming back to school after concussion.  But let’s not forget the school psychologist.  My wife, Mindy Sefton, Psy.D., is trained in concussion management and has crafted some of the best return-to-learn plans I have ever seen.  She works closely with the nurse and classroom teachers to be sure no student be placed at risk for failure. At her middle school there is a protocol for re-entry that is specific and tailored for individual students.
Students with acute concussion and those suffering with post concussion syndrome require assistance at school or risk falling behind their peers.  Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well.  Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation. Student athletes often require support in school while recovering from concussion. Support protocols like reduced work, extra time for tests, and deferred projects are just three commonly prescribed accommodations.
 I am happy to help public schools with their protocols.  They are critically important for student success.  Individual programs can be integrated slowly on a team by team basis depending upon learning style, specific sport and unique student needs.  Dr. Sefton has specialized training in pediatric brain injury, concussion and neuropsychological assessment and is a member of the Academy of Brain Injury Specialists.  Training for coaches and trainers is available and recommended to identify updated return-to-play protocols and current standards of care.  Both web-based and individualized ImPACT testing is available for preseason and after injury assessment.  Return-to-play consultation is available with trainers and team physicians 24/7 at 508-579-0417 and email

School districts interested in using CAMP for supporting athletes injured while playing sports can contact Dr. Sefton at 508-579-0417.  Parents and physicians may call Dr. Sefton at any time to discuss individual injuries and school and sports  re-entry after injury. Post injury testing and neuropsychological consultation is also available. 

HeadacheReturn-to-Learn Care Plan
Some students who are injured playing in school sports may require a return to school care plan.  Dr. Sefton will consult with student, parents, and school personnel to assist with short-term accommodations in school that can assure for continued success in academic domains.  Not all children require changes in their educational programs but careful consideration of the child’s school functioning is essential.
Classroom teachers should be advised to monitor the student athlete for the following signs:
  • Increased problems paying attention/concentrating
  • Increased problems remembering/learning new information
  • Longer time required to complete tasks
  • Increase in physical symptoms (e.g., headache, fatigue) during schoolwork
  • Greater irritability, less tolerance for stressors

“The brain…” a second look at what we know to be true

“The brain, which resides in a jacket of water inside the rigid skull, keeps moving, and rotates forward and backward on the fulcrum of the brain stem.” Jane Brody
NY Times article Feb 13, 2007
Boxer Mike Trowell died in a Glasgow Scotland hospital after sustaining a blow to the head in the first round of a match in 2016
WESTBOROUGH, MA February 5, 2017 This blog was first posted in 2013 and has received little comment. I think it remains important 3 years later because it reveals my understanding of concussion that holds true today.  No athlete should return to play before his or her brain is fully healed AND he has been able to successfully undergo the standardized return-to-play protocol established by the CDC in Atlanta nearly 10 years ago.  In late 2016, Irish Boxer Mike Trowell died shortly after a fight in Glasgow on September 30.  He was knocked down in the first round and visibly injured.  After a standing 8 count he was allowed to continue his match when he was again knocked down in the fifth round. At this point he became unresponsive and was transported to the trauma center where he died after being pulled from life support. He had been having severe headaches for days before his final fight.
Our knowledge of the risk of second impact syndrome (SIS) is grounded in the science that has emerged from autopsy studies of the brains of athletes who have died after years of playing contact sports. The incidence of second impact syndrome is quite rare but it occurs with regularity.  When the brain is not fully healed it can be highly susceptible to a second trauma that results in rapid swelling of the cerebral cortex and the loss of cellular transport that allows for autoregulation of cerebral pressure and normal perfusion.  Read the information below that I first published in 2013.

The quote in the heading of this piece is a quote that was taken from an article written by Jane Brody of the NY Times entitled Hard-Knock Lessons From the Concussion Files. In it, Ms. Brody reviews a published article in the New England Journal of Medicine by  Allan Roper, M.D. and Kenneth Gorson, M.D., neurologists from Saint Elizabeth’s Medical Center in Boston.  As we know, concussion is a serious public health problem and is especially hard on younger athletes.  Female athletes are particularly vulnerable to concussion and tend to have longer recover times. Concussion is sometimes considered an invisible injury largely due to the absence of frank signs of injury on the outside of the head.  It is now the standard of care that athletes not return to play until entirely symptom free.  This can take a week or longer and requires rest.  People sometimes fail to appreciate the cognitive demand of school and work.  Over taxing this system may prolong symptoms of concussion and extend an athlete’s down time.  If an athlete returns to play before he or she is fully healed there is a substantially higher risk of having a second concussion before the first is fully healed.  This can result in a protracted course and months of being on the sideline.  What is worse is the possibility of second impact syndrome, a life threatening condition that results from the brain’s inability to autoregulate perfusion pressure while injured.  It is rare but occurs more frequently than one might think.
Michael Sefton – October 2013

New Biofeedback protocol: Expanded Service for Brain Injury and Trauma

Biograph instrument showing paced breathing protocol by Thought Technologies

WESTBOROUGH, MA April 1, 2016  The Neuropsychology Service at WRH has added both physiologic and EEG biofeedback to the service for those afflicted with concussion, TBI, and trauma. The protocol involves heart rate variability and controlled or paced breathing as a means of gaining enhanced resonance in the autonomic nervous system.  Autonomic storming is a common reaction to traumatic brain injury and can be debilitating over and above the structural changes that impact condition and behavior. It is not new and has utility in treating anxiety and other stress-related conditions.  The protocol is designed to activate the body’s parasympathetic function as a “quieting mechanism” – to put the brakes on for relief and a variety of physical symptoms including pain, irritability, and depression.  The “protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in their body using controlled, paced, breathing and prototypic progressive relaxation” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological services at Whittier Rehabilitation Hospital in Westborough, MA.  Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions.  Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist.  Contact Dr. Sefton for more information of this protocol or an appointment 508-871-2077.

After concussion: When can an athlete begin to exert himself?

WESTBOROUGH, MA March 10, 2016 There is a growing consensus that sooner rather than later may be a better return to play protocol among high level athletes.  The notion that they undergo complete and total rest after being injured may be an unreasonable expectation.  I have previously espoused “total rest” for some athletes I see in practice but I am now realizing an important shift in the current standard of care.

Given the proclivity toward years of daily training among elite athletes – and not so elite athletes I might add, allowing a modest amount of noncompetitive, non-contact exertion may facilitate the recovery process.  The athletes should remain well below his or her cardiac maximum – some say 50-65 % of maximum

Michael Sefton is an avid cyclist and sees concussion patients at Whittier Rehabilitation Hospital in Westborough, Massachusetts

for 10-12 minutes while taking the initial steps toward recovery.  Changes in balance is a common consequence that may result from subtle changes in the vestibular system in the middle ear and/or decreased neurocognitive efficiency. This too can be worked slowly in a controlled rehabilitation setting.

Concussion is a serious injury or force applied to the skull transferred to the brain. It is now well known that injuries to the brain have lasting impact – especially among younger athletes.  The second or third concussion may be vastly different from recovery to the number one injury in terms of recovery time.  This should be monitored by a concussion specialist.  Returning to work and school will also require support.  Return to play protocols are also key for athletes who are injured in season.


Welcome back student athletes – Fall sports 2015!

MIAA requires that all schools report prevalence of concussion on an annual basis

Westborough, MA August 18, 2015 Schools across the country are preparing student athletes to return to the fall sports gridiron.  This week each year I visit several public and private high schools to inform the parents’ of student athletes about the individual concussion programs that each school offers.  Most schools have policies that require physician guided return to play.  As a neuropsychologist and certified school psychologist I want to point out that there is so much more to recovery than just getting back on the field of play.  A school re-entry plan should be put in place after a student athlete sustains a concussion.  This usually means one to three days off from school to allow the brain to heal.

Since July 2010 the MIAA – Massachusetts Interscholastic Athletic Association – the governing body for pubic school athletics has required concussion education for coaches, parents, referees, and athletes themselves.  The idea is to inform everyone about the signs and symptoms of concussion.  Emphasis is now being placed on the athletes themselves to report a concussion before they risk greater injury by returning to play while still experiencing the symptoms of concussion.  The symptoms of concussion have been well described elsewhere including on this website and most parents have taken the online test that is mandated by the MIAA.

As a neuropsychologist in practice in Westborough I have been fortunate to work with excellent athletic trainers, school nurses, and pediatricians as a team providing baseline ImPACT testing, assessment of post-injury concussion, and carefully designed return-to-learn programs, and clearance for return-to-play.  I have assisted several Massachusetts and Rhode Island school districts with writing individual concussion policies that have addressed current “best practice” for dealing with student athletes who suffer head injuries in sport.

MIAA-1024x535The MIAA has begun to allow non-physicians to play a larger role in the return-to-play decisions.  The MIAA website has all of its concussion policies that are here on this link.  This will permit other practitioners with specialized training in concussion management the opportunity to develop return-to-learn plans and to clear an athlete for competition when they are ready.  Physician Assistants, Neuropsychologists, Nurse Practitioners, and some ATC Trainers can now write return to play plans with the appropriate training and careful consideration of each student’s needs.

Congratulations for all those student athletes who worked all summer at captain’s practices – running, skating, playing summer soccer, etc.  Good luck and be safe.  Contact me at Whittier Rehabilitation Hospital for consultation after injury. My policy is to have injured players seen within 72 hours for updated neurocognitive testing and post-injury planning.  When symptoms exceed 7-10 days further assessment and consultation may be needed.  I encourage everyone to see Dr. Evans video posted below to learn more about recovery from concussion.  It takes a care team to help a student athlete get back to school and back to play in a safe way.  Stay in touch with team trainers, physicians, and your school nurse.

Concussion Video released August, 2014 that is interesting and funny by Dr. Mike Evans, a Canadian Internist

Check out Dr. Mike Evans Concussion 101 video – click here

Revisiting Post-concussion Syndrome – When healing takes longer than planned

WESTBOROUGH, MA July 2, 2015 I have recently been referred several cases of unremitting concussion.  What is that? There is a better name for unremitting concussion and its called post-concussion syndrome.  When someone sustains a concussion they can expect that the brain will heal in one to three weeks.  In some cases when the injury is a second or third concussion this timeline may be altered somewhat – generally symptoms are drawn out by days or weeks.  Post-concussion syndrome is diagnosed when the symptoms of concussion extend beyond the three to four-week estimated recovery.  Symptoms of post-concussion syndrome include:

  1. Headaches
  2. Poor concentration
  3. Fatigue
  4. Change in sleep patterns
  5. Decreased memory
  6. Dizziness and changes in balance
  7. Irritability
  8. Sensitivity to light and sound

Remember, a concussion is a traumatic brain injury resulting from a high degree of force or energy being transferred into the brain resulting in an alteration of normal cognitive functioning.  Some call it an “energy” crisis – the brain cannot efficiently access the metabolic nutrients – largely glucose – to accommodate the cerebral demand.  On the Mayo Clinic website they indicate that symptoms of concussion may last as long as 3 months to 1 year.  I can truthfully say I have seen only a handful of cases of post-concussion syndrome that continue over one year.  There are factors that contribute to a protracted course of recovery.  These include specific issues relating to the type of concussion and region of the brain most affected by the trauma.  When symptoms are prolonged it is usually the result of a failure to allow the brain to fully heal before returning to a normal routine.

What can you do if you have symptoms that linger on longer than you expected?  First, take an accounting of your symptom profile.  Be accurate and track the symptoms that seem most problematic.  Do this for 7 days.  Symptoms may be physical, cognitive, sleep-related and/or emotional.  Next, take a look at your level of activity.  If you are back to work, socializing, and exercising regularly than you may be over exerting and should make changes – even temporary ones.  Avoid alcohol while recovering and get ample sleep.  Finally, closely examine the work you are doing and see if there are changes to the work environment that may afford some degree of symptom relief.