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 in the belief - more anecdotal than backed by research - that physical activity may make symptoms worse and has the potential to delay recovery.  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 an athlete recovering from a concussion needs to get physical rest, he needs 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 experts¹ 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.  This means:

• No text messaging
• No video games
• No homework.

Some experts, mindful of the difficulty constantly monitoring a child entails and of enforcing hard-and-fast rules on activities such as video game playing, along with the lack of research in this area, suggest that parents take a more common sense approach about their child's level of cognitive activity, monitoring their child's symptoms and having the child avoid activities that seem to make those symptoms worse.

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 concussions² 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 a growing number of 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	Complete 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	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	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, 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. 

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 the 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 study³ 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,⁴ 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 undergone pre-season, baseline computerized neuropsychological testing, and then re-tested 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);
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.

 

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1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 2009:43:i76-i84

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).

3.  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.

4. 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.f

Revised and updated February 18, 2012.