It’s Not Just Getting Your “Bell Rung”

Jeff Manning, MD- East Greenwich, RI

I’ve heard the expression “getting your bell rung” ever since I started playing football, in 3rd grade.  It never struck me as a particularly ominous expression.  During my years as a high school football coach I clearly remember players and coaches alike using phrases like “he just got his bell rung; he’ll be fine.” It wasn’t until medical school and the more recent media attention on concussion that I started to think about what this phrase communicates.

Despite the current focus on concussion I find that many patients and their families don’t know exactly what it means to have a concussion.  Contrary to the harmless image of a ringing a bell, a concussion is a disturbance in brain function caused by direct or indirect forces to the head.  Concussive forces disrupt neural processes in the brain and affect the way the brain functions.

I spend hours each week trying to explain to frustrated athletes why it is important to rest and take time out of their sport.  There are certainly more coaches, athletes, and parents who take concussion seriously now than there were five years ago, but the continued use of phrases like “he just got his bell rung” really do make an impression on young athletes and minimize the seriousness of concussion.  

Under a recent Rhode Island law, coaches must remove any player who exhibits signs or symptoms of a concussion from a game or practice.  That player must obtain written medical authorization by a licensed physician before being allowed to return to play.

As a medical community we are doing a better job of recognizing and appropriately treating people with concussion than we have in the past.  Nevertheless, athletes are still sometimes making it back to practices and games without resolution of their symptoms or a gradual return to activity protocol.  According to the 2012 Zurich Consensus Statement on Concussion in Sport “The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play.”

The consensus statement goes on to recommend a sample graded program of exertion otherwise known as a “return to play protocol” as outlined in the table below.  With the stepwise progression below, the athlete should proceed to the next level only if he or she has NO symptoms at the current level.  Generally each step should take 24 hours.  Therefore, as long as an athlete remains symptom free he or she would take approximately 1 week to proceed through the protocol.  If any post-concussion symptoms occur during the protocol the athlete should drop back to the level where there were no symptoms and discuss the protocol with their physician. 

Graduated Return to Play Protocol

Rehabilitation Stage

Functional Exercise at that Stage of Rehabilitation

Objective of Each Stage

1. No Activity

Physical and cognitive rest


2. Light Aerobic Exercise

Walking or cycling sub-maximal effort

Increase heart rate

3. Sport Specific Exercise

Running drills (field sports) or skating drills (ice hockey);  no contact drills

Add movement

4. Non-contact Training Drills

Progression to more complex training drills (passing drills in football); may start progressive resistance training

Exercise and coordination

5. Full Contact Practice

Following medical clearance, participate in normal training activities

Restore confidence and assess functional skills

6. Return to play

Normal game play

The next time you hear the words “he only got his bell rung,” think of the translation: “he only suffered a traumatic brain injury which has caused a disturbance in the way his brain functions” – sounds a little different that way, doesn’t it?

Jeff Manning, MD, is a physician who specializes in sports medicine and is the Medical Director of Affinity Sports Medicine, an affiliate of Kent Hospital, located in East Greenwich, RI.  He is also a faculty member with the departments of Family Medicine at Brown University and the University of Massachusetts.  In addition, Dr. Manning sits on the Sports Medicine Advisory Committee of the Rhode Island Interscholastic League. 


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