Following Return-to-Play Guidelines Essential in Concussion Recovery

Sports related concussion (SRC) is a mild traumatic brain injury usually caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain in sport and exercise-related activities.1 Symptoms of a concussion can present within minutes or slowly evolve over the course of hours1. Concussion is not an injury that can be seen on MRI or CT. The symptoms can affect the physical and emotional well-being of the individual who suffered the injury.

Early recognition of a potential SRC and immediate removal from game play for assessment by a health-care professional (HCP) such as a nurse, athletic trainer or physician is vital and is also law in many states. An athlete who continues to play after suffering a concussion is at risk for more significant injury and prolonged recovery2 which could lead to an extended absence from their sport or activity.

Once a concussion has been diagnosed, appropriate return-to-play guidelines need to be followed to ensure a student can recover completely. Guidelines regarding beginning activity and return to play after concussion have been recently updated. Management of students with concussions showing signs of prolonged recovery is critical that it is done appropriately.

Current research no longer recommends “strict rest” until all concussive symptoms have resolved, as this may actually prolong recovery. Instead “relative rest,” which includes activity of daily living and reduced screen time, is recommend.3 After 24-48 hours of relative rest, a student may begin a return-to-learn (RTL) program and consider increasing their physical activity. Physical activity should only be started under the guidance of an appropriate health-care professional, and this activity should be low intensity such as walking or stationary biking.

When participating in low-intensity exercise, the student should avoid any risk of contact, collision or fall.1 This activity should only cause a mild increase in symptoms (i.e., an increase of no more than two points on a 0–10 point scale for less than an hour).1 This activity is not practice or training for sport, but more low-level exercise to prevent deconditioning and keep the student moving and more involved than if they were simply leading a sedentary existence while injured. Loss of physical activity and deconditioning are often associated with higher risk of developing behavioral health problems.

The RTL program may involve students attending partial days initially and advancing to full days of school as tolerated as seen in Table 1.1 Some students may need additional support, help and resources at school based on the severity and character of their symptoms. Most students will have a full RTL with no additional academic support within two weeks of their injury.2 However, some students with prolonged symptoms may find a 504 or IEP helpful. If that is the case, then the school counselors or administration should be involved. It is also recommended that students do not observe sport or practice until they have returned to attending full days of school.

While students are starting RTL, they can simultaneously also begin a return-to-sport (RTS) protocol, although while still symptomatic, it is recommended considering this more as “increasing activity” rather than return to sport.

Under the guidance of a qualified health-care professional, athletes may begin Step 1 (i.e., symptom-limited activity) within 24 hours of injury as seen in Table 21. Each step in the program takes a minimum of 24 hours and progressively increases exertion and coordination. An athletic trainer at school can help monitor a student-athlete throughout RTS. A student should not advance into the later stages that involve risk of head impact (steps 4-6 and step 3 based on sport specifics) without written medical clearance by an appropriate health-care provider. For clearance, every student should have full resolution of concussion-related symptoms with the elimination of all academic adjustments and completion of the RTL program. Progression beyond step 3 requires absence of symptoms with and after physical exertion.1

Approximately 30 percent of athletes with a concussion may have prolonged symptoms lasting more than four weeks.4 Students with symptoms that are not improving over two weeks, or symptoms persisting over four weeks, should be encouraged to consider seeing a specialist with additional training in concussion care. Prolonged recovery can be associated with visual and vestibular disorders, neck pain and behavioral health concerns.5 These students may benefit from working with a multidisciplinary concussion team (physical therapy, behavioral therapy, medical specialist).6

Sports-related concussions can affect a student-athlete in a variety of ways; thus, treatment can be complex. The best practices for management are constantly evolving each year as medical research helps refine strategies. Early return to activity has been shown to not prolong recovery from concussion and potentially improve return to school and reduce recovery times.

Athletes resting in a dark room during recovery is strongly discouraged. It is also important to understand that early activity is not free reign to resume practice and training for sport while symptomatic or without medical clearance. For those athletes where there is concern for prolonged symptoms, early referral to a concussion specialist is important as the specialist can determine the next steps in management to aid in recovery.

Citations:
Patricios JS, Schneider KJ, Dvorak J, et al Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022 British Journal of Sports Medicine 2023;57:695-711.
Putukian M, Purcell L, Schneider K, et al. Clinical recovery from concussion: return to school and sport: a systematic review and meta- analysis. Br J Sports Med 2023.
Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport- related concussion: a systematic review and meta- analysis. Br J Sports Med 2023:bjsports- 2022- 106676.
Master CL, Master SR, Wiebe DJ, Storey EP, Lockyer JE, Podolak OE, Grady MF. Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children. Clin J Sport Med. 2018 Mar;28(2):139-145. doi: 10.1097/JSM.0000000000000507. PMID: 29064869.
Master CL, Bacal D, Grady MF, Hertle R, Shah AS, Strominger M, Whitecross S, Bradford GE, Lum F, Donahue SP; AAP SECTION ON OPHTHALMOLOGY; AMERICAN ACADEMY OF OPHTHALMOLOGY; AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS; and AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics. 2022 Aug 1;150(2):e2021056047. doi: 10.1542/peds.2021-056047. PMID: 35843991.
Babula G, Warunek E, Cure K, Nikolski G, Fritz H, Barker S. Vestibular Rehabilitation as an Early Intervention in Athletes Who are Post-concussion: A Systematic Review. Int J Sports Phys Ther. 2023 Jun 1;V18(3):577-586. doi: 10.26603/001c.75369. PMID: 37425112; PMCID: PMC10324323.