Sports and recreational (SR) activities help to foster important social and team-building skills, while also improving health and quality of life. Unfortunately, participation in SR activity comes with the risk of injury. According to the CDC, an estimated 2.6 million children aged ≤19 years were treated each year in emergency departments (ED) for SR-related injuries during 2001–2009 (1). Around 173,000 (6.5%) of these injuries were diagnosed as suspected Traumatic Brain Injury (TBI). Traumatic Brain Injury is a serious public health concern that has recently received increased media attention especially among professional athletes. However, children and adolescents are considered to have a higher risk for sustaining TBI along with increased severity of injury and take longer to recover when compared to adults (2). Policies and practices are being established to help protect youth athletes from the dangers of SR-related TBI with many states adopting laws to help improve the recognition and response to suspected brain injuries among school-aged children (

What Is a TBI?

A TBI is any head injury that disrupts normal brain function and can be caused by a blow, jolt, or bump to the head or penetrating head injury. The severity of TBIs can range anywhere from a “mild” TBI with a momentary change in mental status to “severe” with an extended period of unconsciousness or amnesia after the injury ( The majority of TBIs that occur each year in the US are concussions or other mild TBI (3).

What Is a Concussion?

Concussions are a type of TBI that can also occur from a fall or blow to the body that causes the brain to move rapidly back and forth within the skull. A concussion may be described as a “mild” TBI by health care professionals because they are typically not life-threatening; however, their effects can be serious ( Depending on the severity of the injury, potential short- or long-term consequences can result in disturbances to the way a person thinks, their emotional well-being, general sensation such as sight and touch, and general language comprehension (4).

Who Is at Risk?

TBIs can occur in any SR-related activity. The number of SR-related TBI ED visits among children and adolescents aged ≤19 years old actually increased 62% (153,375 to 248,418) from 2001 to 2009 (1). This increase in ED visits for TBI among SR activity participants may be the result of increased awareness of these types of injuries. The highest rates for SR-related TBI visits occurred among those ages 10–19 with males accounting for 71% of TBIs amongst all age groups. It is essential that camp staff and even campers understand that TBIs do not only occur during contact sports. Bicycling was the activity associated with the highest estimated number of ED visits for TBI followed by football, playground activities, basketball, and soccer (1). Additionally, TBIs sustained during activities such as horseback riding, all-terrain vehicle riding, and tobogganing/sledding accounted for greater than 10% of all injury ED visits for these activities. Among males aged 10–19, playing football or bicycling were associated with the highest number of SR-related TBI ED visits (1). Females of the same age had the highest rates of visits for SR-related TBI while playing soccer or basketball or while bicycling (1). While these findings emphasize the need for prevention, they also highlight the importance of recognizing the signs and symptoms of TBI as well as how to respond when one is suspected.

How to Recognize a Possible Concussion

To recognize a possible concussion, watch for two main things:

  • A forceful bump, blow, or jolt to the head or body that results in rapid movement of the head,


  • Any changes in the injured person’s behavior, physical functioning, or thinking.

Concussion signs and symptoms, listed in the table below, typically fall under four categories.

Physical Emotional/
thinking clearly
Fuzzy or blurry
Irritability Sleeping more
than usual
Feeling slowed
Nausea or
vomiting (early
Sadness Sleeping less
than usual
Sensitivity to
noise or light
More emotional Trouble falling
Feeling tired,
having no
Nervousness or


These symptoms may not always be apparent immediately after the injury. In some cases, people who have sustained a concussion may not present any effects until days or months later, or when they return to everyday life where more stressors are placed upon them. Concussion symptoms may be difficult to identify initially as a person may seem fine, although they may be acting or feeling differently than normal. A majority of those who sustain a concussion recover quickly and fully, while some have symptoms that last for several days or longer. You can visit to find a list of concussion signs and symptoms specifically related to concussion in sports.

What to Do if a Concussion Is Suspected

Members of your organization play a key role in identifying and responding properly in the event a concussion occurs. Teach all of those involved in SR activities about the importance of recognizing the signs and symptoms and responding quickly and appropriately to a suspected concussion. To ensure early identification and proper management of concussions, develop an action plan before camp begins. You can use the CDC “Heads Up” four-step action plan, which can be included in your camp’s concussion policy (

If an individual is suspected to have sustained a concussion, implement the action plan:

  1. Immediately remove the individual from the activity. If the youth in question has sustained a blow, jolt, or bump to the head or body, look for the signs and symptoms of a concussion. When in doubt, keep the child out.
  2. Ensure the individual is evaluated by a health care professional experienced in concussion evaluation. Do not try to determine the extent of the injury yourself. Instead, record the cause of the injury, if the child lost consciousness and for how long, any memory loss or seizures immediately after the injury, and if the child had any prior history of concussions. Refer the person to a health care professional, and provide your records to that professional.
  3. Inform and educate parents or guardians. Be sure to inform them that their child should see a health care professional with experience in concussion evaluation. Also, give them a concussion fact sheet to educate them about their child’s injury (
  4. Keep the child out of physical activity until a health care professional has determined they are symptom-free and cleared to return to regular activity. Sustaining another concussion before a previous one has fully healed can slow recovery or, in some cases, increase the likelihood of having long-term consequences.

Remember, you cannot see a concussion, and some people may not exhibit signs or symptoms until hours or days after the injury. When developing your own action plan, you can start by identifying a health care professional to respond to injuries during camp. Also, be sure to keep information about the signs and symptoms of concussion and emergency contacts readily available in the event an injury occurs. Be sure that all appropriate staff and health care professionals know and understand the plan you have developed and are trained to use it. Educate campers and their parents or guardians about the dangers of concussions as well. Campers spend a majority of the time with one another, so they can detect concussion signs and symptoms early.

Concussion Prevention

Concussions can occur in any SR activity and are inherent to physical activity. In addition to responding when a concussion does occur, you also play an important role in preventing concus¬sions. Here are a few steps that you can take to minimize the risk for concussions during SR activities:

  1. Teach the importance of good sportsmanship and to follow game rules at all times.
  2. Ensure that protective equipment is worn at all times (e.g., a bicycle helmet).
  3. Coach safe and proper sport/recreation-specific skills and techniques.

For more information regarding SR-related concussion prevention, visit

State Concussion Legislation

Since the passage of the Zachery Lystedt Law in Washington State in 2009, approximately 38 states and the District of Columbia have passed similar laws addressing youth sports concussion among student-athletes. Much like the Lystedt Law, a majority of youth sports concussion laws include three key components of 1) education for coaches, parents, students, etc. regarding concussion among youth athletes, 2) removal of any athlete suspected of sustaining a concussion during a practice or competition, and 3) return to participation only after the athlete has been evaluated and cleared for return by an appropriate health care professional. Many of the laws also require student-athletes and their parents/ guardians to sign a concussion awareness fact sheet to be eligible to participate in school sports programs. Each state law is unique and differs in various ways, including who is considered a “youth athlete.”

Web sites such as the National Conference of State Legislatures ( and NFL Health and Safety ( have detailed information on which states have introduced or passed a law and the specific requirements within each. Additionally, state legislature Web sites allow users to identify and track bills such as youth sports concussion bills if they have not yet been signed into law.

Additional Resources

The CDC has partnered with organizations to help develop guide¬lines to help prevent concussion at no cost. Education is important, as many people still do not fully know how to recognize the signs and symptoms of concussion. CDC has also created the “Heads Up” initiative with a series of materials providing coaches, school and health professionals, parents, and student-athletes information on prevention, recognition, and proper response ( Specifically, the “Heads Up” initiative focuses on:

  1. Using prevention strategies to help reduce the risk for concussion and other injuries,
  2. Stopping an activity if a concussion is suspected and seeking medical evaluation and approval before returning to play, and
  3. Learning concussion signs and symptoms and encouraging athletes and others to report a suspected concussion.

To assist with the prevention and management of concussion, the CDC has developed toolkits for physicians, youth coaches, and school nurses, counselors, and teachers. Additionally, CDC has developed two free online training courses to help with the prevention, recognition, and response to concussion for health care professionals and for youth and high school sports coaches, parents, and student-athletes. Together, the guidelines, toolkits, and training will lead to better outcomes by helping to improve diagnosis of concussion, early detection of signs and symptoms, and use of appropriate concussion management practices.

CDC toolkits:

CDC’s concussion Web site includes links to additional resources where you can access further information regarding TBI, including concussions, in SR activities. Also be sure to investigate the available resources in your local community to determine if there are established youth concussion programs in your area.


  1. Gilchrist J, Thomas KE, Xu L, McGuire LC, Coronado VG. Nonfatal sports and recreation related traumatic brain injuries among children and adolescents treated in emergency departments in the United States, 2001-2009. MMWR 2011: 60(39);1337-1342.
  2. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport—the 3rd International Conference on Concussion in Sport, held in Zurich, November 2008. J Clin Neurosci 2009;16:755–63.
  3. Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
  4. National Institute of Neurological Disorders and Stroke. Traumatic brain injury: hope through research. Bethesda (MD): National Institutes of Health; 2002 Feb. NIH Publication No.: 02-158.

Mr. Lionbarger is a health scientist in the Division of Injury Response of the National Center for Injury Control and Prevention at CDC.  He received his Masters of Public Health in Health Policy and Management at The University of Georgia College of Public Health and has spent the last two years at the CDC researching traumatic brain injury, specifically, state youth sports concussion legislation and TBI rehabilitation.