Youth Concussions And The Knowledge Gap In Recovery
Throughout my career working with contact sports athletes—from youth hockey players just learning to check through college and professional athletes—concussion rehabilitation has been a primary focus of my work. In-season training allocates substantial time toward rehabilitation and injury prevention because these investments determine whether athletes can continue competing safely. Over the years, I've witnessed far too many athletes sustain concussions without receiving proper help from medical professionals. I've seen careers cut short, athletes struggling with lasting side effects that may never resolve, and most tragically, an athlete who took his own life because of the unbearable consequences of his concussion.
These devastating experiences ignited my passion for helping athletes return to play safely. I've dedicated years to understanding concussion pathology and evidence-based rehabilitation. At Kaifas Athlete Development, I follow established medical guidelines from the CDC, Mayo Clinic, and the University of Buffalo Concussion Management Clinic. My mission is clear: help every athlete recover fully and return to sport without risking their long-term health. Yet despite this knowledge being available, a troubling gap persists in how many medical professionals manage these critical brain injuries.
Despite affecting an estimated 1.6 to 3.8 million athletes annually in the United States, there remains a troubling knowledge gap among pediatricians and general practitioners regarding proper concussion recovery protocols. This deficit in understanding leaves young athletes vulnerable to incomplete recovery and potentially devastating consequences that extend far beyond the playing field.
Understanding the Injury: What Is a Concussion?
A concussion is a traumatic brain injury caused by a direct blow to the head, neck, or body that transmits an impulsive force to the brain. This force causes the brain to move rapidly within the skull, stretching and damaging brain cells and creating chemical changes in the brain.
At the cellular level, a concussion triggers a complex pathophysiological cascade. The mechanical disruption causes neurons to release excitatory neurotransmitters indiscriminately, leading to ionic imbalances as potassium floods out of cells while calcium rushes in. The brain responds by working overtime to restore these balances, consuming vast amounts of energy in the form of glucose. Simultaneously, blood flow to the brain decreases, creating an energy crisis at precisely the moment the brain needs fuel most.
This metabolic mismatch—increased energy demand coupled with reduced energy supply—is why concussed individuals experience such profound cognitive and physical symptoms. The brain essentially enters an energy deficit state that requires time and proper management to resolve. During this vulnerable period, which researchers call the "window of cerebral vulnerability," the brain is significantly more susceptible to lasting damage if another injury occurs.
The Six Types of Concussions: Not All Are Created Equal
Recent research has revealed that concussions are not a uniform injury but rather manifest in six distinct clinical subtypes, each with unique symptom patterns and requiring tailored rehabilitation approaches:
1. Cognitive/Fatigue Type
Characterized by mental fogginess, difficulty concentrating, memory problems, and overwhelming fatigue. These athletes struggle with schoolwork and mental tasks that were previously effortless.
Rehabilitation Focus: Gradual cognitive loading with strategic rest breaks, modified academic schedules, and progressive return to mental demands.
2. Vestibular Type
Involves dizziness, balance problems, visual disturbances, and feeling disoriented in space. Athletes may experience vertigo or nausea with head movements.
Rehabilitation Focus: Vestibular therapy exercises, balance training, gaze stabilization activities, and gradual reintroduction to movement.
3. Ocular/Vision Type
Presents with eye strain, difficulty focusing, light sensitivity, blurred or double vision, and problems tracking moving objects.
Rehabilitation Focus: Vision therapy, eye tracking exercises, accommodation drills, and convergence training with an optometrist or vision specialist.
4. Post-Traumatic Migraine Type
Features severe headaches with migraine characteristics including light/sound sensitivity, nausea, and throbbing pain that may worsen with activity.
Rehabilitation Focus: Migraine management strategies, trigger identification and avoidance, progressive aerobic exercise within pain tolerance, and potentially medication management.
5. Cervical/Neck Type
Involves neck pain, reduced range of motion, headaches originating from the neck, and upper back discomfort often from whiplash-type forces.
Rehabilitation Focus: Physical therapy for cervical spine, manual therapy, posture correction, and graduated strengthening exercises.
6. Anxiety/Mood Type
Manifests as heightened anxiety, emotional instability, irritability, sadness, or nervousness that wasn't present pre-injury.
Rehabilitation Focus: Psychological support, stress management techniques, gradual exposure to anxiety-provoking situations, and potentially counseling or cognitive behavioral therapy.
Many athletes present with mixed subtypes, requiring a multifaceted rehabilitation approach. Proper identification of concussion type is critical—generic "rest and wait" advice fails to address the specific dysfunctions present and may actually prolong recovery.
The Critical Role of Light Aerobic Exercise
For decades, the standard concussion advice was simple: rest in a dark room until symptoms resolve. However, groundbreaking research by Dr. John Leddy and colleagues at the University of Buffalo has revolutionized concussion rehabilitation by demonstrating that controlled, sub-symptom threshold aerobic exercise is not just safe—it's therapeutic.
Dr. Leddy's research found that light cardiovascular exercise increases blood flow to the brain, helping to resolve the metabolic crisis at the heart of concussion pathology. Appropriate exercise appears to restore the autonomic nervous system balance, reduce symptoms, and shorten recovery time. The key is finding each athlete's "sweet spot"—the exercise intensity that provides benefit without exacerbating symptoms.
The Buffalo Concussion Treadmill Test (BCTT) helps determine this threshold by gradually increasing exercise intensity while monitoring symptoms and heart rate. Once established, athletes perform daily sub-threshold aerobic exercise, gradually increasing duration and intensity as tolerance improves. This might begin with just 10-15 minutes of walking and progress over weeks to more vigorous activity.
Studies show that athletes who engage in this controlled exercise protocol recover faster than those prescribed complete rest. The exercise must be carefully calibrated—too little provides no benefit, while too much can worsen symptoms and prolong recovery. This nuanced approach requires medical supervision from providers knowledgeable in current concussion protocols.
Recovery Inhibitors: Triggers That Slow Healing
During the vulnerable recovery period, certain environmental factors and behaviors can significantly impede healing and worsen symptoms:
Light Exposure
Bright lights, fluorescent lighting, and screen glare commonly trigger or intensify symptoms. The concussed brain struggles to filter and process visual stimuli, leading to overstimulation. Athletes should wear sunglasses outdoors, use dim lighting indoors, adjust screen brightness to minimum comfortable levels, and consider blue-light filtering glasses.
Noise and Auditory Stimulation
Loud environments—crowded cafeterias, sporting events, concerts—can overwhelm the recovering brain's processing capacity. Background noise that would normally be filtered out becomes intrusive and exhausting. Minimizing auditory stimulation, using noise-canceling headphones, and choosing quiet environments facilitates recovery.
Screen Time and Digital Devices
Smartphones, tablets, computers, and televisions place multiple demands on the concussed brain simultaneously: visual tracking, focus adjustment, information processing, and decision-making. Excessive screen time consistently worsens cognitive symptoms and fatigue. While complete avoidance isn't realistic, screen time should be limited to essential activities with frequent breaks. The 20-20-20 rule helps: every 20 minutes, look at something 20 feet away for 20 seconds.
Dietary Factors
Certain foods and substances can impede recovery:
Alcohol: Absolutely contraindicated during recovery; it disrupts brain healing, worsens cognitive function, and increases vulnerability to further injury.
Caffeine: Can mask fatigue symptoms, leading athletes to overexert themselves, and may worsen headaches and sleep disruption.
Processed foods and added sugars: Promote inflammation and fail to provide nutrients needed for brain repair.
Inadequate hydration: Dehydration worsens concussion symptoms and impairs cognitive function.
Instead, athletes should focus on anti-inflammatory, brain-supportive nutrition: omega-3 fatty acids (fish, walnuts, flax), antioxidant-rich fruits and vegetables, adequate protein, and consistent hydration.
Inadequate Sleep
Sleep disruption is both a symptom and a complicating factor in concussion recovery. The brain conducts critical repair processes during sleep, yet concussions often cause insomnia or fragmented sleep. Prioritizing sleep hygiene—consistent schedule, cool dark room, no screens before bed—is essential.
Cognitive Overload
Returning to full academic demands too quickly overwhelms the energy-depleted brain. Athletes need academic accommodations including reduced workload, extra time on assignments, frequent breaks, and potentially delayed return to testing. Pushing through symptoms doesn't build resilience—it prolongs recovery.
The Dangers of Second Impact: Why Complete Recovery Matters
Perhaps the most critical reason for proper concussion management is preventing second impact syndrome (SIS) and cumulative neurological damage. When an athlete sustains a concussion before fully recovering from a previous one, the consequences can be catastrophic.
Second impact syndrome, though rare, is often fatal. It occurs when a second concussion happens during the window of cerebral vulnerability, causing rapid and severe brain swelling. The mortality rate exceeds 50%, and survivors often face permanent neurological disability. SIS predominantly affects young athletes whose brains are still developing.
More commonly, repeated concussions before complete recovery lead to prolonged symptoms, increased recovery time, and cumulative brain damage. Athletes with a history of concussion are three to six times more likely to sustain another. Each subsequent concussion requires less force to occur and takes longer to recover from—a progressively worsening cycle.
Long-term consequences of repetitive head trauma include chronic traumatic encephalopathy (CTE), a neurodegenerative disease causing memory loss, confusion, impaired judgment, depression, and eventually progressive dementia. While CTE has received attention primarily in professional athletes, research increasingly shows it can develop from youth sports concussions, particularly when managed improperly.
Research demonstrates that the developing adolescent brain is particularly vulnerable to concussion effects. The prefrontal cortex, responsible for executive function and decision-making, develops into the mid-twenties. Disrupting this critical developmental window with repeated brain trauma can have lasting impacts on cognitive function, emotional regulation, and academic achievement.
The Knowledge Gap: Where Healthcare Falls Short
Despite these serious implications, many pediatricians and general practitioners lack comprehensive training in current concussion management protocols. A concerning percentage still prescribe outdated "dark room rest" recommendations without proper symptom subtyping, exercise protocols, or individualized return-to-play planning.
This knowledge deficit stems from several factors: concussion research has evolved rapidly in recent years, outpacing medical education curricula; concussion management requires time-intensive evaluation and follow-up that conflicts with brief appointment schedules; and many providers lack access to specialized concussion clinics or interdisciplinary teams.
The result is young athletes receiving well-intentioned but inadequate care. They're cleared for return-to-play based on being "symptom-free" without objective testing of vestibular, ocular, or cognitive function. They receive no guidance on therapeutic exercise or subtype-specific rehabilitation. They return to sports prematurely, remaining vulnerable to devastating second impacts.
Comprehensive Concussion Management: The Path Forward
Proper concussion care requires a systematic, evidence-based approach:
Immediate Response: Remove athlete from play immediately when concussion is suspected. Never allow "playing through" concussion symptoms. Initial evaluation by medical professional within 24-48 hours.
Comprehensive Assessment: Detailed symptom evaluation, identification of concussion subtype(s), baseline cognitive testing when available, vestibular and ocular motor screening, and cervical spine evaluation.
Individualized Rehabilitation Plan: Subtype-specific interventions, graduated aerobic exercise protocol starting with Buffalo Concussion Treadmill Test, appropriate specialists referrals (vision therapy, vestibular therapy, physical therapy, neuropsychology), academic accommodations, and trigger management strategies.
Return-to-Play Protocol: Athletes must complete a graduated six-stage return-to-play progression without symptom exacerbation:
Light aerobic exercise
Sport-specific exercise (no head impact)
Non-contact training drills
Full-contact practice
Full game play
Each stage requires 24 hours minimum. Any symptom return requires dropping back to the previous level.
Return-to-Learn Protocol: Concurrent graduated return to cognitive activities, progressing from brief, low-demand activities to full academic load with supports, then eventually full unrestricted academics.
The Research Foundation: Learning from the Experts
The protocols described here aren't theoretical—they're grounded in rigorous research from leading concussion experts. Dr. John Leddy's team at the University of Buffalo has been instrumental in developing and validating exercise-based concussion treatment. Their research demonstrated that athletes who engage in controlled aerobic exercise recover faster than those prescribed rest alone, fundamentally changing concussion management.
Dr. Leddy and colleagues have published extensively on the Buffalo Concussion Treadmill Test, autonomic dysfunction in concussion, and physiological approaches to rehabilitation. Other pioneering researchers include Dr. Michael Collins at the University of Pittsburgh Medical Center Sports Medicine Concussion Program, who has advanced understanding of concussion subtypes and individualized treatment; Dr. Gerard Gioia at Children's National Hospital, who developed comprehensive pediatric concussion assessment tools; and Dr. Christopher Giza at UCLA, whose work on concussion pathophysiology has illuminated the cellular mechanisms underlying injury and recovery.
This body of research consistently emphasizes several key principles: concussions are heterogeneous injuries requiring individualized treatment; complete rest beyond the first 24-48 hours may prolong recovery; controlled exercise is therapeutic when properly dosed; return-to-play decisions must be objective, not symptom-based alone; and the developing brain requires special consideration and conservative management.
Conclusion: Athletes Deserve Better
Young athletes dedicate countless hours to developing their skills, pushing their bodies, and pursuing excellence in their sport. They deserve healthcare providers who are equally dedicated to understanding the complexities of concussion—an injury that, unlike a broken bone, remains largely invisible but can have profound and lasting consequences.
The current state of concussion care, with its knowledge gaps and outdated protocols, puts our young athletes at unnecessary risk. Every pediatrician and general practitioner who treats young athletes has a professional obligation to become educated in current concussion research and evidence-based rehabilitation protocols.
This means moving beyond generic "rest until better" advice to comprehensive, individualized care. It means understanding that not all concussions are the same and that the athlete with vestibular symptoms needs different treatment than one with cognitive/fatigue or anxiety symptoms. It means recognizing that appropriate exercise is medicine, not something to avoid. It means identifying and mitigating recovery inhibitors like excessive screen time, poor nutrition, and cognitive overload.
Most critically, it means understanding that clearing an athlete for return-to-play is not simply about being symptom-free—it's about ensuring complete physiological recovery so that re-entering contact sport doesn't risk catastrophic second impact syndrome or cumulative neurological damage that could affect that young person for the rest of their life.
Healthcare providers must commit to ongoing education, consulting research from experts like Dr. Leddy and his colleagues at University of Buffalo and other leading concussion researchers. Athletes, parents, coaches, and schools must demand this expertise, understanding that proper concussion care isn't a luxury—it's a medical necessity.
The young athlete with a concussion is not simply sidelined temporarily from sport. They are a patient with a brain injury in a critical window of vulnerability, a developing human whose cognitive, emotional, and neurological future depends on receiving knowledgeable, comprehensive care. Our healthcare system must rise to meet this responsibility. The stakes—measured in young lives and futures—could not be higher.
