Research Shows Students’ Academics Affected by Concussions

A recent study published in American Academy of Pediatrics June 2015 Pediatrics (published online on May 11, 2015) looked at concussion and its effect on academic performance. The research included a sample of 349 students, ages 5 to 18, who sustained a concussion and whose parents reported post-injury academic concerns on school questionnaires. The type and intensity of the students’ concussion symptoms were measured as an indicator of the severity of their injury.

Researchers found that actively symptomatic students and their parents had heightened concerns over the effects of the students’ concussions on their school performance, as well as increased school-related problems than their recovered peers. In other words, the students’ level of post-concussion symptoms had a direct relationship to the extent of academic effects.

Eighty-eight percent of students with symptoms reported school problems due to headaches, fatigue and concentration issues, while 77 percent reported issues such as needing to spend more time on homework, difficulty taking notes, and studying.


Additionally, high school students in the study who had not yet recovered reported significantly more adverse academic effects than their younger counterparts. The greater the severity of their concussion symptoms was also associated with more school-related problems and worse academic effects, regardless of time since injury.

Every state has concussion legislation generally requiring three basic criteria in the event of a concussion:

  • The removal of a child from play
  • A structured return to learn
  • Clearance from a concussion specialist

However, most youth aren’t athletic professionals and many of them do not advance to participate in college and professional athletics. Currently, only Nebraska and Virginia have return-to-learn legislation indicating that concussed athletes may need specific informal or formal accommodations at school and that school personnel should be trained in concussions. In light of students’ limited number of years of sports and because of recent proven research, legislation should be in place in every state to provide more extensive accommodations after a brain injury so that students’ academics are not adversely affected.

To review each state’s legislation, please visit:

World Cup Again Brings Up Concussion Debate

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

It’s no secret in my family that I’m a die hard sports fanatic. I count the U.S. Women’s National Soccer Team’s win over China in 1999 as one of the greatest sporting events in our country’s sporting history – rivaled only by the win of the U.S. Hockey team over the Russians at the 1980 Olympics. Naturally, I was glued to the TV over the past few weeks while our U.S. Women’s National Soccer Team again clinched the World Cup championship last week.

Backtracking to the team’s semifinal game against Germany, analysis stated the U.S. did a great job on offense and defense, although the Germans came out hard with a flurry of shots and dominated the first 20 minutes of the action. Then, iIn the 28th minute, Germany’s Alexandra Popp went to head a ball on a free kick and USWNT’s Morgan Brian was having none of that and went up to meet her. The action happened so fast you could really tell what happened until FOX sports showed the replay. It turned out that Popp’s and Brian’s heads had violently collided.

Jun 30, 2015; Montreal, Quebec, CAN; United States midfielder Morgan Brian (14) and Germany forward Alexandra Popp (18) collide attempting a header during the first half of the semifinals of the FIFA 2015 Women's World Cup at Olympic Stadium. Brian and Popp were injured on the play. Mandatory Credit: Eric Bolte-USA TODAY Sports ORG XMIT: USATSI-230278 ORIG FILE ID:  20150630_ajw_bb5_045.jpg

Jun 30, 2015; Montreal, Quebec, CAN; United States midfielder Morgan Brian (14) and Germany forward Alexandra Popp (18) collide attempting a header during the first half of the semifinals of the FIFA 2015 Women’s World Cup at Olympic Stadium. Brian and Popp were injured on the play. Mandatory Credit: Eric Bolte-USA TODAY Sports ORG XMIT: USATSI-230278 ORIG FILE ID: 20150630_ajw_bb5_045.jpg

We all know the showmanship that sometimes appears in soccer when players grab a shin or a knee and throw themselves to the ground only to be up and running about at full speed moments later. But, when players are truly injured, their teammates are taught at a young age that whomever has the ball should kick it out of bounds so the hurt players can be attended to by medical personnel. The Popp-Brian collision was the first time I can ever remember the referee stopping the play prior to the ball actually going out of bounds.  After slamming heads, both Popp and Brian fell awkwardly to the turf.

Medical personnel from both teams game out and examined both players for 4 minutes and both teams played 10-on-10 for several minutes before both players returned to play the remainder of the game. Although neither player was knocked unconscious, the mechanism of injury was serious enough to have warranted a full 24 hours of observation before they should have been permitted to return to play.

Actions that FIFA can take to help teams and doctors make play safer for the players could include:
– have an impartial doctor on the sidelines, much like the referees who are from countries other than the teams playing, who can help assess injured players and protect the organization from future lawsuits; and
– add a substitute for teams in case a FIFA doctor rules that an injured player can’t return to the game to eliminate some of the pressure to keep playing.

Injuries like the Popp-Brain collision help drive home the point that kids younger than 14 shouldn’t be using their heads in recreational games until they are taught the right techniques and when their bodies have fully developed.

I’ve always said the benefits of sports far outweigh the risks, but that precautions need to be taken seriously. The risk of a head trauma is that athletes returning too quickly to play can suffer a second injury that could prove to be career-ending or, in the worst possibly case, fatal. Clinicians, parents, coaches and league administrators need to continue to evaluate the rules of sports collisions to ensure the safety of our children, the vast majority of whom will need their brains for something other than headers in the World Cup.

Is Discussion About Concussions in Youth Soccer Being “Gagged” by Officials at the Highest Level of the Sport?

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director
and Ann-Marie Sedor, HeadFirst Concussion Care Marketing

A recent story out of Louisville, Ky., is that US Youth Soccer is trying to “gag” its state officials from having public conversations about concussions in their sport. US Youth Soccer is the largest member of the United States Soccer Federation, the governing body for soccer in the United States, and has 3 million registered players between ages five and 19.

Unfortunately, leaders of US Youth Soccer have declined to discuss why the organization issued a memo encouraging soccer leaders not to talk to the media both generally and specifically concerning upcoming concussion stories. However, a statement on their website says they are not trying to ‘muzzle’ their membership but instead to create one singular communication channel to avoid inaccurate or conflicting information.

The president of the Kentucky Youth Soccer Association President said the request came from the United States Soccer Federation, their parent organization, and was sent out as a precaution because of the pending lawsuit filed in California that seeks only to change playing rules rather than monetary damages.

Soccer officials at the state level aren’t buying it. Oliver Barber, a lawyer who is chairman of the Kentucky Soccer Referee Association and a volunteer coach was quoted as saying “I don’t like US Youth Soccer telling us not to address such an important issue. We have a whole lot more work to do to keep players safe.”

Like many sports today, soccer administrators at all levels of the sport, including youth, high school, college, Olympic and pro, are experiencing pressure from parents, athletes, referees, and the community to address the issue of concussions. Over the past year or so, soccer officials have been struggling with rule changes such as whether or not to let players head the ball under the age of 14. Two of the top proponents of avoiding ball heading at a young age include former U.S. international soccer star and World Cup champion Brandi Chastain and Dr. Robert Cantu, a leading expert on head trauma in sports and a clinical professor of neurosurgery at Boston University School of Medicine.

Girl Heading Soccer Ball - 2

A number of studies have shown that soccer players have developed CTE (chronic traumatic encephalopathy) and experience cognitive changes from frequent heading of the ball. The damage occurs, not as a result of a single concussive injury (although these injuries also occur in soccer), but as a number of cumulative hits in which the brain moves. These hits are called subconcussive trauma, and while scientists don’t have a handle on the defined threshold before injury appears, there is clear evidence in their research that heading the ball over time produces structural changes which can be observed in neuroimaging.

As soccer administrators in the United States continue to formulate rule changes to protect our children and protect the integrity of the game, parents can and should continue to be their child’s best advocate with regards to safety.

Parents can:

Honoring Brain Injury Awareness Month

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

Since HeadFirst Sports Injury and Concussion Care launched just three years ago, we’ve already seen the tide turn about the public’s understanding of concussion (mild Traumatic Brain Injury or mTBI). We’ve gone from hearing “It’s a only a mild concussion,” and “You just got your bell rung a bit,” to an acknowledgment of the severity of this silent injury.

Locally here in the Capital region, HeadFirst has been extremely active in hosting educational seminars for coaches and parents, and participating in dozens of community outreach programs.

In 2014 alone, HeadFirst’s team of professionals participated in more than 80 community events reaching more than 180,000 people. These events included partnerships and sponsorships with the Brain Injury Association of Maryland, Hockey for Heroes (benefitting the Wounded Warrior Project, USA Warriors Ice Hockey Program and Disable Veterans of America), Sports Legacy Institute, Touchdown Club of Annapolis, as well as educational seminars for school and county recreational coaches and athletic directors, presentations for school nurses on concussions and mental health, and attendance at community health fairs.

These groups have welcomed our educators with open arms to help their coaches and athletic trainers understand the right protocol in managing a suspected head injury, from those critical first moments to long-term treatment for proper healing.

Our outreach programs are one of our cornerstones, we’d like to think they’ve helped change the traditional way of thinking about concussions.

HeadFirst is also a gathering point for professionals from around the region to share their expertise. Our monthly Concussion Consortium pulls together physicians, neurologists, neuropsychologists, physical and vision therapists, and other specialists, school administrators and nurses, athletic trainers and coaches, who discuss scientific research and resources for concussion treatment and protocols.

The Consortium often hosts a respected guest speaker who shares information about specific topics and issues related to concussion. Next week, we’re welcoming Sarah Loeffler, LCSW-C, of The Neuropsychiatry Program at Sheppard Pratt Health System in Baltimore, Md., who will discuss mTBI’s connection to anxiety and depression.

Also next week, HeadFirst Chief Executive Officer Robert G. Graw, Jr., M.D., and HeadFirst Program Director Tony Doran, Psy.D., are presenting their lecture, An Integrated Community Model for Concussion: Update, at the Brain Injury Association of Maryland’s annual conference.

Of course, all of this is in addition to our 11 clinics throughout the DC-Baltimore region, which is our reason for existence. From the thousands of neurocognitive ImPACT® tests we’ve administered to the patients for whom we have cared, we’ve heard amazing, heartfelt stories of the trials of living with a concussion and the willpower to overcome it. These serve as our inspiration to push ever forward.


We continue to read emotional articles in the news about concussion awareness, including yesterday’s announcement of San Francisco 49er linebacker Chris Borland’s decision to retire due to the high potential of long-term brain injury from playing. Turning away from a lucrative career in the name of your health surely must be one of the most incredibly difficult decisions to make, and we applaud this young man for having the guts to make this choice.

HeadFirst Sports Injury and Concussion Care is proud to honor March’s designation as Brain Injury Awareness Month, as well as Brain Injury Awareness Day today, March 18. Looking back, it’s been a fulfilling journey, albeit a short one. The starting line is still in our sights and we know the finish line is a long way off—and very likely will continue to move even as we do.

Concussions can and do happen to anyone, anytime, anywhere. The non-discriminatory nature of this injury is what continues to motivate us to do our work.

What’s Missing in Youth Concussion Laws

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

A recent Fox Sports article discusses the youth concussion laws that have passed in all 50 states and the District of Columbia, but it also highlights some key elements that were missed.

Over the past five years, each state has modeled their laws after the State of Washington law in 2009, also known as “The Zackery Lystedt Law” after a high school athlete who suffered a life-changing concussion (pictured below, pre-injury and today, with his father).Zackery-Lystedt

Unfortunately, only 21 states have implemented all four key components of Washington’s law, which is considered the gold standard by many professionals:

This is pretty basic. The science and medical reasons for asking a child or athlete to leave a game or practice when a concussion is suspected is in place so a second and potentially more dangerous concussion does not occur. As of today’s writing, neither Illinois nor Wyoming requires the removal of an athlete from play in such a scenario. Arizona and South Carolina allow an athlete to return to play the same day if cleared by a physician.

When a child is suspected of having a concussion, it is a good idea to at least wait 24 to 48 hours after the injury to ensure that symptoms do not develop. Here at HeadFirst, as many as 40% of our patients develop symptoms one to two days after their injury.

Fortunately, this is not as opposed as it was just three or four years ago. Coaches now realize the importance of receiving education about how to evaluate and treat a head injury. New York law requires not only coaches but also nurses, athletic trainers, and teachers to receive training on concussion and concussion management.

But New York is the exception and there are many states that don’t require education about concussion. Researchers and scientists also still need to do much in this area. Studies have not been completed on what coaches and athletic trainers know prior to training and what type of training is effective.

This is quite a basic component of the law which requires student athletes and parents to sign an informed consent stating they understand the dangers of the sport and that a concussion or traumatic brain injury is one of the risks involved in the sport.

Only 30 states have this element as part of their laws requiring clearance by a trained concussion healthcare provider prior to injured athletes’ return to play. Many laws and training programs also do not specify what training a concussion specialist needs or requires.

Even though these elements are a good first step, they’re still not enough to protect our children. A carefully designed return-to-learn plan is just as important in concussion recovery since academic demands can slow brain healing. Unfortunately, only two states—Nebraska and Virginia—have return-to-learn elements within their concussion guidelines. These procedures require a school to be notified if a student has sustained a concussion and then to give that student accommodations due to the injury.

Some states have even made unsuccessful attempts to add supplementary requirements to their concussion laws.

Oklahoma tried to add a section to their law that would mandate suspensions and punishments on coaches and athletic trainers who didn’t follow concussion guidelines.

Massachusetts attempted to add required neurocognitive baseline testing for all high school students.

And, Maryland tried to add a requirement of helmet sensors on high schoolers’ helmets before basic scientific research had been completed on the sensors or the meaning of a positive or negative sensor result.


A number research studies continue to suggest the negative effects of alcohol (and other recreational drug use) after brain injury.

Alcohol is a neurotoxin — meaning alcohol kills brain cells — exacerbating the effects of a concussion. There is no recommended safe amount of alcohol or recreational drug use after a concussion. Even moderate amounts of alcohol for people with a concussion have been associated with increased deficits in memory, attention and balance.

Additionally, heavy pre-injury alcohol consumption is associated with poorer health outcomes and substance abuse post-injury. Many concussion patients report they are more sensitive to the effects of alcohol after injury. Even a small amount of alcohol after a concussion can impair judgment and increase the risk of a fall (and subsequent head injury).

How Much “Strict Brain Rest” is Needed After a Concussion?

by Majid Fotuhi, M.D., Ph.D.
Founder & Chief Medical Officer, NeurExpand Brain Center
Guest Contributor

Guidelines by the American Academy of Neurology, American Academy of Pediatrics, and many sport organizations emphasize the importance of brain rest after a mild TBI. Now, a new study published in the January 5 issue of Pediatrics questions the validity of recommending 5 days of strict rest to all children who suffer a concussion.

Authors examined the difference between the outcomes of two groups of children (average age of 13-14 years old) who presented within 24 hours of a head injury to an emergency room. Half were told to rest for as long as needed, usually for 1-2 days, followed by stepwise return to the usual level of activity. The other half was told to rest for 5 days, without engaging in any school or work engagements, followed by stepwise return to activity. Participants had neurocognitive (ImPACT) and balance assessments at baseline and at their follow-up visits at 3 and 10 days. They also kept a diary of their activity level and how they felt.

In both groups, 60% of participants reported resolution of their symptoms. However, half of the “strict rest group” took 3 additional days to reach a full recovery. This strict rest group also tended to have a larger amount of emotional issues, as they were kept away from school and social settings. Children in the strict rest group who had headaches at the onset of their concussion tended to have lingering symptoms for a longer period of time than the control group. The one exception to better outcomes in the control group was for children who had immediate loss of consciousness or amnesia at the time of their injury. These children seemed to benefit from 5 days of strict brain rest.


In general, it appears that not all children who experience a mild TBI should receive a prescription for strict 5-day brain rest. There may be benefits in treating each patient individually, depending on their initial symptoms, level of cognitive function, and severity of concussion. Some may need no rest, some may need 1-2 days of rest, and yet others may need 5 or more days of avoiding demanding brain stimulation.  More studies are needed before the current guidelines can change. The one recommendation that is gaining more support in recent years is to have patients engage in exercise early in their post-concussive period.  Increasing physical activity tends to do wonders for rehabilitation of patients who suffer from a stroke (which is a vascular brain injury) and it may be just as beneficial for kids or adults who have had a traumatic brain injury.

For now, if you have had a brain injury, please be sure to see your doctor or a sports medicine specialist who is familiar with concussion management issues. Your brain is a precious organ and it’s important to work with experts in the field  on controlling your symptoms and finding the best resolution for full recovery. Otherwise you may end up having lingering post-concussive symptoms for months, years, or decades.

SOURCE: Anderson, P. (2015, January 7). Strict Rest After Concussion Offers No Additional Benefit.

Concussions Can Affect Processing Time in Speech and Language

by Melissa D. Stockbridge, M.Sc.
Guest Contributor

Even a relatively minor head trauma can result in physical, cognitive, behavioral, and social consequences for a young patient. Specific effects of mild brain injury or concussion on language ability can include effects on the ability to think of the names for things, make sentences, and interact with others appropriately in social situations. Many studies have linked brain injury to difficulty reading and telling stories.

Anomia, or difficulty thinking of the names for objects or people (essentially, severe “tip-of-the-tongue” experiences), is the most common reported symptom that affects language. Problems with naming can have big impacts in the classroom. Imagine not being able to come up with the name of the main character in a novel or the particular term you need to name in your science class!

Not only is the accuracy of coming up with the names of objects affected (e.g., saying “dog” when viewing a picture of a dog), but also there is an increase in the time that it takes the patient to come up with the name.

This can be imagined by analogy to a computer connecting to the Internet that may eventually load a webpage correctly, but the connection is much slower than usual.

SpeakExamining differences in the “processing time” required to name an object may be useful in better understanding the cognitive changes that occur during the period of spontaneous recovery directly following a brain injury.

Researchers at the University of Maryland, College Park, are examining naming accuracy and processing time across the period of spontaneous
recovery from mild head trauma, in order to better understand the changes in young people with brain injuries.

Patients at HeadFirst Concussion Care between the ages of 10 to 20 years of age are being recruited to name rapidly presented images on a computer that measures how quickly they say the name of that image. It is predicted that adolescents with concussions will demonstrate a steep rate of recovery of naming accuracy to within normal range, with a slower recovery of processing time beyond that point.

It is our hope that this information will improve information available to clinicians and patients in making return-to-learning and return-to-play decisions and will add to what is known about how a minor injury may impact performance in language or in education.

Melissa D. Stockbridge is an M.A./Ph.D. student at the University of Maryland’s Department of Hearing and Speech Sciences