Return to play (RTP) after a child or teen suffers a sport concussion is a step-by-step, graduated, exercise-limited process:
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.  Broad restrictions of physical activity are recommended, including:
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 conclusive link has been established to adverse long-term health effects)
As a result, both the most recent international consensus of concussion experts  and, most recently, the American Academy of Pediatrics  recommend that athletes limit scholastic and other cognitive activities to allow the brain time to heal.
Cognitive rest means:
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  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.
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.
A 2010 study of high school athletes with concussions   reported that:
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 .
A number of recent studies suggest that concussed adolescents, perhaps even more than younger and older athletes, need longer to recover full cognitive function and should be held out of play longer. One study  found that concussed adolescents have difficulty recovering the ability for high level thinking after injury and may require extended recuperation before full recovery of so-called 'executive function' is achieved, with researchers at the University of Oregon and University of British Columbia finding that executive function was disrupted in concussed adolescents for up to 2 months after injury when compared to healthy control subjects.
In the absence of daily testing by a health care professional with concussion expertise (certified athletic trainer, school/team/primary care/sports medicine physician, neuropsychologist) 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. This means that, for such athletes, return to sports will take at least two weeks. Some leading concussion experts, including Dr. Rosemarie Scolaro Moser, a sports concussion neuropsychologist featured in the new PBS documentary, "The Smartest Team: Making High School Football Safer,"  recommend taking a minimum of three weeks off before returning to sports after a concussion.
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.
As young athletes tend to consider only a small subset of their potential symptoms when reporting their recovery  or saying they are "back to normal" after concussion, caution is urged in considering athletes' self-reported symptoms in their return-to-play decisions, and the same caution is warranted in relying solely on neurocognitive test scores having returned to normal before the graduated exercise protocol is begun.
Indeed, a recent study   of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated exercise protocol, found that more than a quarter exhibited declines in verbal and visual memory on the tests after moderate exercise, prompting a recommendation that student-athletes not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on neurocognitive concussion testing performed after the exercise protocol is begun. While this was only one study, additional post-exercise neurocognitive testing may eventually become an important part of the RTP protocol.In practical terms, this more conservative approach means that:
Return to play after concussion should follow a six-step process:
|1. No activity
||Symptom limited physical and cognitive (e.g. mental) rest (see above)
|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
|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   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 usually the best qualified to decide when it is safe for an athlete to return to play.
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:
In their desire to return to the playing field, some high school athletes fail to comply with return to play guidelines. A 2009 study  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 now-outdated American Academy of Neurology (AAN) and then current Zurich return-to-play guidelines.
A 2011 study ,  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:
A 2013 study   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."
"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 ,  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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Most recently updated August 30, 2013