Sports concussion: A return-to-play guide

At 16 days’ follow-up (20 days from injury), KD had returned to school full time and said she felt more like herself, although she continued to have daily headaches and phonophobia. All exam results were normal. Sports were still off limits, and we told her to expect at least 7 more days of respite before any return to exercise would be allowed.

At 23 days’ follow-up (27 days from injury), KD’s symptoms had completely resolved, and all exam results were normal. We prescribed a stepwise return to athletic activity over the next 10 days and discussed this plan with the school’s athletic trainer, who would supervise her return to play.

Individualize management

The one-size-fits-all approach previously recommended⁶ is no longer the standard of care. In your initial encounter with the patient (and parents, as appropriate), explain the nature of the injury, expected course of recovery, and requirements for a return to play. Also discuss the possibility of postconcussive syndrome and the risk of rare sequelae such as second impact syndrome.

If the patient is symptomatic or exhibits examination findings consistent with concussion, recommend immediate cessation of sports activity.^9-12 With a school-aged athlete, if symptoms reported by the patient or parents are significant, consider prescribing cognitive rest, which can be provided through quiet accommodations at school or perhaps even time off from school or exams.^12,24 In the early period of recovery, increased cognitive or physical activity can cause symptoms to worsen. With improvement, the patient may return to school half time to lessen the chance of a significant return of symptoms. If half days are tolerated, the patient may transition to full days. Make sure the diagnosis and expectations for recovery are communicated to the appropriate school officials so that necessary accommodationscan be made. If symptoms after the initial office visit are mild, a one-week return to school is appropriate to evaluate the patient’s recovery.

Allowing a return to sports. Once the patient is asymptomatic, and physical and cognitive test results are normal, discuss a return-to-play protocol with the patient (and with parents and athletic trainer or coach, as appropriate). Multiple sources^10,11,26 now recommend a stepwise return to play, as detailed by the 3rd ICCS ( TABLE 2 ).¹² Increase or decrease the length of the protocol depending on the patient and the specifics of the case.

There is little science to guide the treatment of children with concussion. However, given that their brains are still developing, it’s prudent to be more conservative than with older adolescents or adults. Multiple sources apart from the 3rd ICCS agree with this recommendation. Several authors suggest more cognitive rest and a longer return-to-play protocol in all cases.^10,27 In fact, the ICCS committee additionally recommends observing a symptom-free waiting period for pediatric athletes before even starting a return-to-play protocol.

McCrory et al²⁶ suggest that children under age 15 be treated more conservatively than those 15 and older. They suggest treating those 15 and older with the protocol for older adolescents. Specifying an age at which one should always make a decision for or against conservative care can be problematic. However, based on the recommendations above, it would seem reasonable to provide conservative treatment for children younger than high school age and perhaps even those in the early years of high school.

Consider legal implications. Become familiar with state laws that require certain steps in managing sports concussion. The Web site https://www.sportsconcussions.org/laws.html²⁸ lists states with sports concussion statutes, as well as states with bills working their way through the legislative system. Currently, 29 states are listed with laws; 14 more and the District of Columbia have pending legislation.

TABLE 2
Stepwise protocol for return to play