Coach's Corner: Sam Knopik 5/20

Sam Knopik

By Sam Knopik Pembroke Hill Head Coach
Posted: May 20, 2011 - 8:31 AM

Look no further than the front page of the Kansas City Star or the New York Times on any given day and you will find articles relating to head injuries and football. The issue is real and high school coaches would be wise to understand the issue in its entirety as it applies to young men playing high school football.

Frustrating for the high school coach is the attack on our game and the perception of how we coach the game based on effects seen in the NFL veteran. However, the issue is real and you are no doubt experiencing the effects of this focus in several ways.

Missouri coaches should be cognizant of HB 300* which awaits approval from the State Senate and is expected to pass unanimously by Dec. 1, 2011. On the Kansas side of the state line, your version of HB 300 is called House Bill 2095 and Senate Bill 33.

While newspaper and sports related media outlets are giving the topic of traumatic brain injury (TBI) more coverage as of late, the sports government communities around the world have been aware and actively working to address this issue for years.

Most significantly, the third International Conference on Concussion in Sport was held in Zurich, Switzerland in 2008. This conference was the third of such held on the topic since 2001 which first met in Vienna, Austria. The purpose of the Zurich conference was build upon the work done at conferences in Vienna and later, Prague to produce a document that could be used by “physicians, therapists, certified athletic trainers, health professionals, and coaches” in the understanding of issues related to sports-related concussions.

Most everything affecting the high school football coach regarding TBI is coming from recommendations of the Zurich Statement**. It should be reviewed by every combat sport coach in your schools and especially your athletic directors and athletic trainers.

In the fall of 2008 a committee of “non-government, non-advocacy panel was assembled to give balanced, objective and knowledgeable attention to the topic” of athletically induced TBI. This panel “included researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sport science.”

What this committee produced was a document that effectively addresses the identification of TBI, return to play (RTP) criteria, differences between adults and youth (under 18), various peripheral contributors to TBI, role of preventative measures, and the role of organizations in diligently working to educate others on this topic.

Below is a recap of the major points of the Zurich Statement as it applies to high school football, however I suggest you download a copy from the link below and read it in its entirety as well. All direct quotes come from the Zurich document.

Part 1 What is a concussion and how should it be defined?

Due to the dynamic nature of evaluating brain injuries the committee established a broad definition which includes probable cause by “a direct blow to the head” or an “impulsive force transmitted to the head.”

Part 2.1 What are the symptoms?

The following domains are identified in diagnosing a concussion:

  • Symptoms: headache, “feeling as if in a fog”, emotional instability

  • Physical Signs: loss of consciousness, amnesia

  • Behavioral Changes: irritability

  • Cognitive Impairment: slowed reaction times

  • Sleep Disturbance: drowsiness

Part 2.2 Evaluating a concussion on the field or on the sideline

  • First and foremost the player needs to be evaluated with standard first aid protocols.

  • The player’s injury should be seen by a trained medical professional on the spot or taken immediately to one, depending on the severity of the injury.

  • Only after the first aid needs are met should an “assessment of the cognitive injury be made.” The Zurich Committee established a tool known as the SCAT2 for this purpose. Importantly, but unfortunately, often overlooked in the evaluation of symptoms is the role of physical signs and balance. The SCAT2 exam accounts for signs of loss of balance functions in test 2, 6 and 7.

  • Supervision of the player should occur over the hours following the injury.

  • A player suspected of TBI, or mild traumatic brain injury (MTBI) should not return-to-play (RTP). In certain cases the Zurich Consensus allowed adults the provision to RTP under certain circumstances but NEVER youth. Youth athletes were defined as under the age of 18.

While “sideline evaluation of cognitive function is an essential component in the assessment of this injury,” such as the SCAT2, any tests done on site are not to “replace comprehensive neuropsychological (NP) testing; nor should they be used as stand-alone tool for ongoing management of sports concussions.”

So, when attempting to diagnose an athlete’s injury on-site if he were to show any signs, symptoms of MTBI through the determination by a medical professional OR suspected by a coach, the player must not RTP. If using tools such as the SCAT2 it should be recognized that the SCAT2 is useful in determining the injury and recovery, but should not replace more comprehensive evaluations by a medical professional in the on-going recovery process.

Part 4 Managing the concussion

The Zurich Consensus outlines a graduated step process of recovery in which an athlete can only move on to the next step once he accomplishes or is symptom free of the previous step. Through this recovery process the athlete should be on physical and cognitive rest, such as limited physical exertion and modified academic work, avoiding text messaging, video games, etc…

Part 4.1 Graduated RTP Protocol

Each step should take no less than 24 hours to complete. The best case scenario is for an athlete to RTP after 6 days of recovery. However, the youth athlete should be treated more conservatively.

Rehab Stage

Functional Exercise


1.       No activity

Physical and cognitive rest


2.       Light aerobic exercise

Walking, low intensity, no resistance training

Increase Heart Rate

3.       Sport-specific exercise

Running drills, no contact

Added movements

4.       Non-contact training drills

Progression to more dynamic drills such as pass routes, no contact

Exercise, coordination with cognitive work

5.       Full contact practice

Only after medical clearance to participate in a complete practice

Restore confidence, assessment of recovery and functional skills by coaching staff

6.       Return to Play

Normal game participation



Part 4.2 Return to Play on the same day?

As mentioned above, while this is allowed under certain conditions with adult athletes it is not recommended by the Zurich Consensus in youth. If it is determined that the athlete has indeed suffered a concussion Missouri HB 300 is vague on immediate RTP, however, in light of the Graduated RTP Protocol it is hard to support that scenario.

Part 4.4 The role of prescription drugs in the recovery process

The Zurich Consensus also maintains that before an athlete is cleared to RTP he not only needs to be “symptom free but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of a concussion.”

Part 5.1 How significant is loss of consciousness when diagnosing the severity of injury?

This is a dramatic and terrifying event on site. It should be noted by the coach/athletic trainer and any information regarding the length of loss of consciousness (LOC) should be reported to the medical professional. However, “LOC has not been noted as a measure of injury severity.”

Part 5.2 How significant is amnesia when diagnosing the severity of injury?

Again, surprisingly, amnesia is a variable that when treatment in the recovery process is considered in whole, plays a small part in determining the severity of the injury.

Part 5.3 Convulsive Movements

When an incident of head trauma is accompanied by motor twitching by the athlete it can cause great concern. However, “these dramatic, clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.”

Part 5.4 Depression

While the side effect of depression has been cited very publically regarding the long-term health of the NFL athlete we are unaware of the long-term mental health of youth. With the conservative model still in play however, the mood of the injured athlete should be considered through the recovery process.

Part 6.1 Applying the Zurich recommendations to adolescents

“There was unanimous agreement by the panel that the evaluation and management recommendations could be applied to children down to the age of 10.”

The role of a baseline test is addressed to remind all that the development of the adolescent brain would require a periodic establishment of a baseline score. Additionally, athletes with learning disorders or attention deficit disorders may need more “sophisticated assessment strategies.”

Most importantly, it is in this section where the Zurich Consensus is clear regarding RTP Protocols for youth. “It is not appropriate for a child or adolescent athlete to RTP on the same day as the injury regardless of the level of athletic performance.”

Part 6.3 Does chronic TBI exist?

While the anecdotal cases are reported and depending on the high profile nature of case studies it would appear that there is a connection with TBI and long-term health. However, the Zurich Consensus did not come to a conclusion on this issue but recommend to health professionals to be mindful of the potential for long-term problems.

Part 7.1 What is the role of protective equipment?

While studies have shown a significant decrease in the event of “impact forces” to the head they are inconclusive in regards to reduction of concussions. Obviously, marketing and technological advancements are being made in this field. Coaches are advised to do their due diligence in placing too much credit in the hands of protective equipment as the catch-all for injury prevention.

Part 7.2 What role do playing rules have in the prevention of injury?

It is the author’s belief that enforcement of the rules already in effect in the game of high school football, specifically NFHS Rule 2-20-1***, can greatly and immediately impact the prevention of MBTI in young athletes. Furthermore, the Zurich Consensus notes, “that rule enforcement may be a critical aspect of modifying injury risk… and referees play an important role in this regard.”

Part 7.3 Is there an increased risk of injury due to improved equipment?

This is an interesting twist of good intentions especially in youth aged sports. It appears that there are behavior changes made because of the perceived lowering of risk due to protective equipment which in fact can create a more dangerous environment.

Part 7.4 Coaches are asked to emphasize sportsmanship

The Zurich Consensus acknowledges that there is an element of aggression in sport and that fair play should never be forsaken for violence. In addition they call on organizations to “address violence that may increase the concussion risk.”

Part 8 The importance of spreading the word.

Return to Play protocols as outlined in the Zurich Statement should be made available to all stakeholders in the process. “Athletes, referees, administrators, parents, coaches and health care providers must be educated regarding the detection of concussion, its clinical features, assessment techniques and principles of safe RTP.”

Organizations who believe in, and support, the principles of the Zurich Statement are encouraged to make that fact known.

Part 10 A disclaimer of sorts.

The Zurich Statement should not, nor is it intended to be, a “standard of care.” Rather it should be considered a “guide, consistent with the reasonable practice of a heath care professional.”

In closing, we have found most of the recent legislation, return to play practices, and evaluation exams, such as the SCAT2, to have come directly from, or heavily influenced by, the Zurich Statement. We hope coaches can become informed participants in the process. Considering our role in the rest of our game this should not be too much to ask.

*For a closer look Missouri HB 300:

**To download a copy of the Zurich Statement:

***For a recap of NFHS Rule 2-20-1:

Sam Knopik is the head coach at Pembroke Hill.