Gradual Return to Play After Concussions Recommended

 

Return to play (RTP) after a child or teen suffers a sport concussion is a step-by-step, graduated, exercise-limited process:

1. Physical and mental (e.g. cognitive) rest while experiencing symptoms
2. Exercise program of gradually increased intensity (but only after symptoms clear)
3. Medical clearance
4. Return to play (1).

Physical rest

While bed rest is not required, strenuous activity  should be avoided until the athlete has no post-concussion symptoms at rest, with at least one study showing an association between athletes engaging in activities requiring high levels of physical exertion and greater impairment on computerized neurocognitive testing (e.g. ImPACT testing) and reports of more concussion symptoms (8).  Broad restrictions of physical activity are recommended, including: 

• no sports
• no weight training
• no cardiovascular training
• no PE classes
• no sexual activity
• no leisure activities such as bike riding, street hockey, and skateboarding that risk additional head injury or make symptoms worse. 

Cognitive rest

Just as athletes recovering from a concussion needs to get physical rest, they need to get cognitive (mental) rest as well.

Because a concussion impacts the brain's cognitive function (those that involve thinking, concentrating, learning and reasoning), not its structure, it makes sense that engaging in cognitive activities (in other words, doing something that requires thinking or paying attention ) is likely to make an athlete's concussion symptoms worse (although no link has been established to adverse long-term health effects)

As a result, both the most recent international consensus of concussion experts (1) and, most recently, the American Academy of Pediatrics (2) recommend that athletes limit scholastic and other cognitive activities to allow the brain time to heal. 

Cognitive rest means:

1. Time off from school or work;
2. No homework;
3. No reading;
4. No visually stimulating activities, such as computers, video games, texting or use of cell phones, and limited or no television;
5. No exercise, athletics, chores that result in perspiration/exertion;
6. No trips, social visits in or out of the home; and
7. Increased rest and sleep (7).

Such rest has been recommended despite the fact that, until June 2012, there was no empirical evidence to support such treatment. With the publication of a new study in the Journal of Pediatrics (7) documenting the effectiveness of prescribed rest for the treatment of post-concussion symptoms and cognitive disfunction, whether the rest is applied in the early or prolonged stages of recovery,  athletes, parents, and school and athletic officials who do not see the therapeutic value of missing school or sports, especially when weeks or months have passed since the injury, it is hoped, will now be less likely to resist or challenge such clinical judgment.

Post-concussion classroom accommodations 

Once physical symptoms clear, but before exercise is allowed, a gradual return to a full academic day can begin, with classroom accommodations.

At the Lawrenceville School, a New Jersey prep school, for instance, a concussed athlete must stay in the infirmary on "strict rest in a darkened room with no iPod, no computer, and no reading" until his or her physical symptoms of concussion are at or close to their pre-injury baseline. At that point, he or she is gradually allowed to return to a full academic day, long-time Medical Director, Dr. Robin Karpf, tells MomsTeam.  "Their short-term memory and processing speed may continue to be off their baseline, but as long as they are not experiencing significant physical symptoms, I allow them back to the classroom with academic accommodations." (An e-mail is sent to all the athlete's teachers with information on the possible need for such accommodations).

"We need to do more to educate teachers that adjustments may need to be made for a concussed athlete,"  Dr. Karpf said. Kids who don't get cognitive rest, she has found, are more likely to have concussion symptoms that linger longer.

If the increased cognitive challenges of the classroom bring about a recurrence of their physical symptoms, Dr. Karpf says, she returns them to rest.  She does not start their gradual return to exercise or sports until they have returned to their neurocognitive baseline.

Conservative approach

A 2010 study of high school athletes with concussions (3) reported that:

• 27.0% had symptoms clear in less than 24 hours
• 36.2% between 1 and 3 days,
• 20.2% between 4 and 6 days,
• 15.1% had symptoms lasting more than a week but less than a month; and
• Only (1.5%) were still experiencing symptoms more than a month after injury. 

Experts nevertheless caution that, while an estimated 80 to 90% of concussions heal spontaneously in the first 7 to 10 days, children and adolescents may require a longer rest period and/or extended period of non-contact exercise than adults because their developing brains cause them to experience a different physiological response to concussion than adults and take longer to recover, and they have other specific risk factors, such as the risk of second impact syndrome. 

In practical terms, this more conservative approach means that:

• Children and teens should not, under any circumstances, be allowed to return to practice or play until completely free of symptoms; 
• No return to play on the same day as the injury, regardless of competitive level (as is now the law in an all but a handful of U.S. states); and
• "Modifying factors" (i.e. previous history of concussion, learning disabilities), take on more importance in the investigation and management of concussion. 

Return to play guidelines

Return to play after concussion should follow a six-step process:

Stage	Activity	Objective
1. No activity	Symptom limited physical and cognitive (e.g. mental) rest (see above)	Recovery
2. Light aerobic exercise	Walking, swimming or stationary bicycle keeping intensity less than 70% of maximum predicted heart rate; no resistance training	Increase heart rate
3. Sport-specific exercise	Skating drills in ice hockey, running drills in soccer.  No head impact activities	Add movement
4. Non-contact training drills	Progression to more complex training drills, e.g. passing drills in football and ice hockey; may start progressive resistance training	Exercise, coordination and use of brain
5. Full contact practice	Following medical clearance, participate in normal training activities	Restore confidence and allow coaching staff to assess functional skills
6. Return to play	Normal game play

 

While many of the youth sports concussion safety laws passed by the states in recent years contain broad language allowing any "qualified health care professional" to make the return-to-play decision, studies show that many primary care physicians (10) lack the expertise required to make return to play decisions.  Because they have more training and experience in concussion diagnosis and management, certified athletic trainers, team doctors, and neuropsychologists are the best qualified to decide when it is safe for an athlete to return to play.

 

7 + days to recover

Generally, each step should take at least 24 hours, so that, assuming the athlete does not experience a reoccurrence of concussion symptoms at rest or with exercise as she progresses through the exercise program, she will be able to return to sports in about a week's time after symptoms have cleared.   

If any post-concussion symptoms occur at any level, the athlete needs to drop back to the previous level at which she was symptom-free, and try to progress again after a further 24-hour period of rest has passed.

As suggested in the Model Policy and Guidance for Prevention and Treatment of Sports-Related Concussions and Head Injuries recently issued by the New Jersey Department of Education pursuant to that state's concussion safety law, in the absence of daily testing by a health care professional with concussion expertise (certified athletic trainer, school/team physician) to clear a student-athlete to begin the graduated return-to-play protocol:

• A student-athlete should observe a 7 day rest/recovery period before commencing the protocol.
• Younger students (K-8) should observe the 7 day rest/recovery period (after they are symptom-free at rest) prior to initiating the graduated-return-to play protocol. 

Non-compliance is serious problem

In their desire to return to the playing field, some high school athletes fail to comply with return to play guidelines.  A 2009 study (4) by researchers at Nationwide Children's Hospital in Columbus, Ohio found that at least 40.5% and 15.0% of athletes who sustained concussions returned to play prematurely under the American Academy of Neurology (AAN) and Zurich return-to-play guidelines.  

A 2011 study (5), however, shows for the first time the important role computerized neuropsychological testing is playing in concussion assessment and return to play decisions. Athletes who had taken a pre-season, baseline ImPACT computerized neuropsychological test, and took the ImPACT test again after suspected concussion were less likely to return to play on the same day, and less likely to return to play within a week of their injury, than the three out of four injured athletes who did not undergo such testing.

The authors suggested three possible reasons:

1. that the computerized tests are more reliable in guaging whether an athlete's cognitive functioning had returned to baseline than self-reporting by athletes of signs and symptoms (which, in the interest of a quick return to play, an athlete may downplay or fail to report altogether)(a hypothethesis,as noted below, which was confirmed in a more recent study (6));
2. that the use of such tests by those providing concussion management leads them to be more conservative in return-to-play decisions; and
3. that neurocognitive testing is used more often in cases of severe concussions that require extended recovery times before return to play.

Athletes' perception of recovery

According to a 2012 study (6), young athletes tend to consider only a small subset of their potential symptoms when reporting their recovery or that they are "back to normal" from concussion, basing recovery more on an absence of somatic symptoms (e.g., headache, vomiting, visual disturbances, etc.) and not on the more subtle, and difficult to detect, symptoms of concussion such as "fogginess," difficulty concentrating or remembering, and slowed reaction time.  Clinicians should thus exercise caution in considering athletes' self-reported symptoms in their return-to-play decisions.  

Because adolescent athletes are considered a high-risk population for sustaining an additional injury or long-term damage following a sports-related concussion, it is crucial that symptomatic athletes not be allowed to return to play.  To ensure a more cautious return-to-play decision, a multidisciplinary approach that includes objective neurocognitive testing such as with the ImPACT test in conjunction with athletes' self-reports is recommended because such testing may detect the more subtle and elusive cognitive symptoms and deficits of concussion that athletes, particularly males, tend to underreport (6).  

Post-exercise neurocognitive testing recommended 

In fact, a 2013 study (9) of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated return to sports protocol, found that more than a quarter (27.7%) exhibited declines in verbal and visual memory on the tests after moderate exercise. 

The findings prompted the study's authors, led by sports concussion neuropsychologist Neal McGrath, Ph.D. of Sports Concussion New England, to recommend that neurocognitive testing become an "integral component of the athletic trainer's post-exertion evaluation protocol and that student-athletes should not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on such post-exertion neurocognitive concussion testing."

"Given the unreliable nature of self-reported symptoms in athletes, a group typically motivated to return to play and minimize symptoms, the sensitivity of computerized neurocognitive testing to incomplete recovery and the importance of identifying any indicators that an athlete may not remain stable in his/her baseline functioning prior to return to contact sports action, post-exertion neurocognitive testing appears to be a logical tool to consider." 

"Our thinking," said McGrath, "is that since exercise is known to cause recurrence of symptoms in some athletes who may not be fully recovered, and since neurocognitive testing has been shown to reveal persisting cognitive deficits in athletes who say or feel that they are symptom-free (6), any significant decline in post-exercise cognitive test scores for those athletes who have reached the point of feeling fully symptom-free, with resting neurocognitive scores that are back to baseline, would indicate that more recovery time is needed before returning to contact sports action. We would follow those athletes until their post-exercise neurocognitive test scores remain stable at baseline levels before clearing them to return to play." 

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1. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br. J. Sports Med. 2013:47:250-258.

2. Halstead, M, Walter, K. "Clinical Report - Sport-Related Concussion in Children and Adolescents"  Pediatrics. 2010;126(3):597-615.

3.  Meehan W, d'Hemecourt P, Comstock D. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

4.  Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005-2008.  Brain Inj. 2009:23(11):888-98.

5. Lincoln A, Caswell S, Almquist J, Dunn R, Norris J, Hinton R. "Trends in Concussion Incidence in High School Sports: A Prospective 11-Year Study"Am. J. Sports Med.accessed January 31, 2011 @http://ajs.sagepub.com/content/early/2011/01/29/0363546510392326.

6. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012).

7. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics DOI: 10.1016/j.jpeds.2012.04.012 (in press).

8. Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR. et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance.  J Athl Tr. 2008;43:265-274.

9. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP.  Post-exertion neurocognitive test failure among student-athletes following concussion.  Brain Injury 2013;27(1):103-113.

10.  Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric Providers' Self-Reported Knowledge, Practices, and Attitudes About Concussion. Pediatrics 2012;130(6). DOI: 10.1542/peds.2012-1431)(published online ahead of print)(accessed November 19, 2012)

Most recently updated March 12, 2013