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Applying Concussion Guidelines in Real World: Return to Play Advice Will Vary

Some Guidelines Allow Earlier Return Than Others


Individualized management required


Because the science of concussion is evolving, management and return to play decisions remain a matter of clinical judgment on an individualized basis1 which takes into account a number of so-called "modifying factors":

  • The severity of the current injury (especially loss of consciousness longer than 1 minute)

  • How long the symptoms persist (including persistent symptoms with exertion)

  • Whether there has been prolonged cognitive impairment (e.g. memory, concentration problems)

  • Whether the athlete has learning disabilities (ADD, ADHD etc.)

  • Whether the athlete has suffered repeated concussions over time, and if so, the number, severity, proximity in time to current injury. An athlete with a previous concussion during the season is at 3 to 4 time's greater risk for suffering a second concussion. The risk of concussion increases further after each subsequent concussion.

  • The sport the athlete is playing. An athlete participating in a non-contact, low-risk sport can, in all likelihood, be returned to play sooner than an athlete returning to a high-risk, collision sport, such as football or wrestling.

  • Whether repeated concussions are occurring with progressively less impact force

  • The athlete's age (a child's developing brain is believed to react differently to trauma than a mature brain.

Input from an athlete's parents and teachers should be sought.

In general, a more conservative return to play approach should be followed for children and teens.

Some hard and fast rules

While concussion management is largely a matter of clinical judgment, several hard and fast rules have emerged:

  1. A player with a diagnosed concussion should not be allowed to return to play on the day of injury, even if an athlete athlete and even if a high level of medical care is available on the sports sideline;

  2. Children should not be allowed to return to practice or play until completely symptom-free.

  3. Physical and cognitive rest is required, which activities that require concentration and attention (e.g. limited or no scholastic work, videogames, texting or text messaging).  School attendance and activities may need to be modified to avoid making symptoms worse.

1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 20090: 43:i76-i84.

Updated and revised July 20, 2009