“It wasn’t a horrible thing where she fell over or anything like that,” McDonough says. “We looked for bumps or any kind of raises to put ice on, and she said, ‘No, I’m fine. It’s OK.'” McDonough asked the student—a senior in high school—if she felt dizzy or confused, and she said no, but McDonough asked her to sit out the rest of class, just in case. That turned out to be the right call. The next day, she had a headache and her doctor diagnosed a concussion. She missed three weeks of dance.

Whether a dancer gets a concussion in or outside the studio, she will need to take time off and re-enter class gradually. If a dancer comes back before her concussion heals, she risks life-threatening complications or endangering other dancers. If someone hits her head in your class, you’ll need to know what to watch for to make sure the student gets the treatment she needs and resumes training safely.

How Concussions Happen

A concussion is a type of traumatic brain injury. It’s often caused by getting hit in the head, but it can also result from whiplash or violent shaking. The force of rapid acceleration or deceleration from the blow or shake causes the brain to move suddenly inside the skull, which can cause the brain to swell and temporarily alter its chemical levels. The injury is not rampant in dance like it is in football, but it’s still an issue. A 2014 study published in the Journal of Dance Medicine & Science details the cases of 11 dancers who suffered concussions during class, rehearsal or performance. They happened in all styles of dance, caused by everything from falls and drops (sometimes where another body part hit the floor first, like an elbow or the buttocks) to whipping the head and neck during choreography or getting hit with a stage prop. There is no typical dance concussion.

Reacting in the Moment

If a dancer hits her head in your studio, it may require more attention than other injuries. The British Journal of Sports Medicine created the Pocket Concussion Recognition Tool (available for free online) to help non–health professionals quickly check for concussions in children, teen and adult athletes.

There are physical signs you can look for, like being slow to get up after the hit or fall, being unsteady or uncoordinated, clutching the head, acting confused or unaware of recent events or losing consciousness. You should also ask the dancer about symptoms you can’t see: nausea, drowsiness, sensitivity to noise or feeling “in a fog.” Asking memory questions can be helpful, too. The Recognition Tool lists examples like “What venue are we at today?” and “Who scored last in this game?” which can easily be adapted from sports to dance, with questions like, “What exercise did you do last?” or “What piece are we rehearsing?”

If you suspect a dancer could have a concussion, she should be removed from participating in class and be evaluated by a physician.

There are also some red flags that require a trip to the ER: if the student complains of any neck pain, shows increased confusion or irritability or other behavior change, vomits repeatedly, seizes or convulses, experiences weakness or tingling/burning in arms or legs, or has a severe or increasing headache or double vision.

Dancing Through It

Even if the dancer seems fine after her hit or fall, make sure her guardian knows she’s been hit in the head—even if another body part hit the ground first and appears to be more injured. Symptoms of a concussion can take a while to show. In the 2014 study, concussions were identified anywhere from a few hours to three months after the incident, which means students can dance through a concussion for weeks or months without knowing they have one.

Tell your students that they should not ignore headaches or any other symptoms of concussions after a fall or hit. They should see a doctor who can perform neurological tests and, if necessary, brain-imaging tests to assess the damage.

Risks and Recovery

Doctors prescribe mostly rest—physical and mental, with no texting, TV and limited reading—for healing a concussion. Headaches, dizziness and difficulty thinking can last a few days, weeks or sometimes even months. In the study, dancers had symptoms everywhere from several days to more than three months. One dancer, who hit her head on the floor while flipping over the back of a partner in modern class, experienced headaches and fatigue for more than two years.

Insist that your dancer listen to her doctor about how much time off she needs. Consider requiring a doctor’s note before allowing her to resume classes. Returning too early can be extremely dangerous. In the worst-case scenario, if a student experiences a second concussion while the first is still healing, it can cause the brain to swell—often fatally. More typically, she’ll find herself feeling head pain, and if she’s still having balance or coordination troubles, she could bump into other students and cause more injuries.

A Smooth Return to Class

The study outlines stages of returning to activity from a concussion, adapted from other sports to dance. The length of each stage depends on the severity of the concussion and should be discussed with a doctor, but the trajectory generally follows a course from pure rest and recovery to light aerobic activity like gentle walking, swimming or stationary cycling; then going back to class for just a barre or warm-up; slowly resuming center work, turns and jumps; getting back into tumbling and partnering; and finally returning fully to all classes, rehearsals and performances.

Unfortunately, once a dancer has had one concussion, she’s at greater risk for another one. When another of McDonough’s students, who’d gotten a concussion from a car accident, insisted she was feeling better and ready to compete, McDonough let her try taking class. She could quickly tell the dancer needed more time to recover. “After one class I said, ‘You’re not dancing. You’re done.’ She was tired quickly, and her head was hurting her. It was visible to me that it was not a good idea.”