The return of high school sports brings with it the return of the many injuries that happen while participating in practices and games. Concussions are one of the most common injuries as it is estimated that approximately 1.0–1.8 million sport-related concussions (SRC) occur per year in the United States.
Concussions, which can also be called minor traumatic brain injuries (mTBIs), occur by a direct blow to the head or body, resulting in the rapid acceleration and deceleration of the brain within the skull. This causes functional impairment and microscopic damage to cells within the brain, resulting in a variety of temporary symptoms, which most commonly include headache, dizziness, nausea, fogginess, balance issues and difficulty concentrating. While the severity of each individual concussion varies, most concussions will resolve in 21 days or less. Coaches and school administrators should be knowledgeable about how to recognize signs and symptoms of a concussion so that a qualified medical professional can promptly evaluate the athlete for a potential brain injury.
Previously, the standard of care for concussion had been physical and cognitive rest until symptom resolution. It was felt that rest would minimize post-concussion symptoms and would also promote recovery by minimizing brain energy demands. This restis- best approach was based on animal research and expert consensus guidelines.
Recent research has demonstrated that there is no harm and that there is certainly a multitude of benefits to allowing prescribed and monitored physical activity during the recovery period. The newest expert consensus guidelines have now changed to reflect these advances. Specifically, this new research has shown that return to exertion within the first week can actually speed recovery, reduce the risk of prolonged effects of concussion, improve mood, improve sleep, improve blood flow to the brain, and positively affect the ability of the nervous system to re-regulate.
Immediately following a concussion, the student should be advised to follow cognitive and physical rest for 24-48 hours. After this initial period, students should start integrating back into normal daily activities, including participation in school and non-contact physical exercise. Concussed students should follow an expose and recover model. This entails exposing the student to a cognitive or physical activity, such as school, homework, walking or other daily life activities while monitoring their symptoms.
Activities that increase the students’ symptoms more than two points on a 0-10 scale, should be temporarily suspended until the symptoms have decreased either back to the starting level or at least a lower, manageable level. Once the symptoms decrease, the student should return to the activity, continuing to monitor symptoms and pausing the activity again after another increase of two points on a 0-10 scale.
Students should aim to attend school daily, but based on symptom severity, they might need accommodations. After 48 hours of cognitive rest, most students should be able to attend at least partial days of school, increasing to full days of school as soon as possible to reduce material missed and limit social isolation. As the student returns to the classroom, he or she may be provided with specific academic accommodations to allow the student to participate in classes without significantly increasing their symptom burden, while also providing a level of cognitive rehabilitation and environmental exposure to the brain.
The accommodations each student receives should be tailored to the student’s specific symptom set and course load. Common academic accommodations include, but are not limited to, pre-printed notes, preferential seating, longer time limits for testing, and postponed deadlines for homework and assignments. Academic accommodations are provided by a qualified medical professional and are continuously reviewed and modified as the student progresses through their recovery.
Along with returning to the classroom, students benefit from engaging in low-risk physical activity exercises such as walking, stationary biking and jogging after 24-48 hours of physical rest. This exertion is best done under the supervision of a health-care professional such as an athletic trainer or physical therapist. The expose and recover model allows students to engage in non-contact exercises as tolerated and lets them progress to activities that are more strenuous, such as running, elliptical and sport-specific training drills, as they recover. Students should be completing daily physical activity in a controlled, monitored environment, avoiding the potential for another hit to the head. Students should not be allowed to return to full sport participation until all symptoms have resolved and the student has been evaluated and cleared by a qualified medical professional.
Research has also shown that students who are isolated from their teams and social circles experience a longer recovery and more emotional distress than those who remain active with their social support systems. If symptoms allow, they benefit from attending practices, team meetings and games as sideline spectators. Students can participate in practices and events with activities such as scorekeeping and directing drills to help maintain their engagement with their team. Along with maintaining physical contact with their support system, many students use social media to connect with their peers. Students may engage in normal screen-time, including using their phones, tablets and computers as symptoms allow, continuing to use the expose and recovery model for these activities.
Students should be advised to follow a regimented sleep schedule. The brain requires sleep to aide in recovery, but excessive sleep/rest can be detrimental. Regular bedtimes and wake-up times should be maintained throughout the recovery process and nightly sleep should not be less than seven hours or exceed 9-10 hours per night. The student should also avoid naps throughout the day, as napping often disrupts the wake-sleep cycle, resulting in more difficulty with nighttime sleep and recovery. Caffeine consumption should be avoided four hours before sleep, and electronics should not be used at least 30 minutes prior to regular bedtime. Sleeping should be done in a dark, cool room. Sleep machines or fans may be used to drown out ambient noises or to provide background noise.
Proper hydration and a steady diet are vital to the recovery of a concussion. Students are advised to drink plenty of fluids throughout the recovery process. The ideal hydration is water, but other hydrating beverages such as sports drinks or lemonade may also be consumed. Excessive caffeine use, such as energy drinks and coffee, is discouraged during this time. It is important that concussed students maintain a regular eating pattern without skipping meals. Changes in appetite can occur in the initial stages of a concussion, but students should be encouraged to eat a well-balanced diet and incorporate protein-rich foods throughout the day.
Knowledge of concussions is constantly evolving, which creates the need to evolve the treatment as well. Students should no longer be confined to dark rooms until all of their symptoms have resolved. Guiding students through a protected, regulated treatment plan of physical exercise, cognitive exertion, sleep, hydration and diet helps promote the recovery of this injury.
Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, Valovich McLeod TC; National Athletic Trainer’s Association. National Athletic Trainers’ Association position statement: management of sport concussion. J Athl Train. 2014 Mar-Apr;49(2):245-65.
Haider MN, Bezherano I, Wertheimer A, Siddiqui AH, Horn EC, Willer BS, Leddy JJ. Exercise for Sport-Related Concussion and Persistent Postconcussive Symptoms. Sports Health. 2021 Mar;13(2):154-160.
Harmon KG, Clugston JR, Dec K, Hainline B, Herring S, Kane SF, Kontos AP, Leddy JJ, McCrea M, Poddar SK, Putukian M, Wilson JC, Roberts WO. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med. 2019 Feb;53(4):213-225.
He JW, Tu ZH, Xiao L, Su T, Tang YX. Effect of restricting bedtime mobile phone use on sleep, arousal, mood, and working memory: A randomized pilot trial. PLoS One. 2020 Feb 10;15(2):e0228756.
Kita H, Mallory KD, Hickling A, Wilson KE, Kroshus E, Reed N. Social support during youth concussion recovery. Brain Inj. 2020 May 11;34(6):782-790.
Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, Suffoletto HN, Leiter J, Cordingley DM, Willer B. Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2019 Apr 1;173(4):319-325.
McCrory P, Meeuwisse W, Dvořák J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA, Ellenbogen R, Emery C, Engebretsen L, Feddermann-Demont N, Giza CC, Guskiewicz KM, Herring S, Iverson GL, Johnston KM, Kissick J, Kutcher J, Leddy JJ, Maddocks D, Makdissi M, Manley GT, McCrea M, Meehan WP, Nagahiro S, Patricios J, Putukian M, Schneider KJ, Sills A, Tator CH, Turner M, Vos PE. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847.
Popovich M, Almeida A, Freeman J, Eckner JT, Alsalaheen B, Lorincz M, Sas A. Use of Supervised Exercise During Recovery Following Sports-Related Concussion. Clin J Sport Med. 2021 Mar 1;31(2):127-132.
Kelsey Hansen, MA, ATC, is an athletic trainer who serves as a concussion specialist with the concussion program at Sanford Orthopedics & Sports Medicine in Sioux Falls, South Dakota Josefine Combs, PsyD, is a clinical neuropsychologist and the clinical director of the concussion program at Sanford Orthopedics & Sports Medicine in Sioux Falls, South Dakota Verle Valentine, MD, FAMSSM, FACSM, is a sports medicine physician and the medical director of the concussion program at Sanford Orthopedics & Sports Medicine in Sioux Falls, South Dakota. He is the medical director of the Sanford Sports Science Institute, an assistant professor at the Sanford School of Medicine of the University of South Dakota, and team physician for South Dakota State University. He is also a past member of the NFHS Sports Medicine Advisory Committee (SMAC)