A 16-year old soccer player was playing in a pre-season scrimmage on a Friday afternoon when a player from the opposite team kicked a ball that hit her on the side of the head with force. She immediately fell to the ground in pain and was helped off the field by her teammates. She was taken to the athletic training room where she was assessed and it was determined she had a concussion.
Exam: VS normal. She is alert and oriented to her surroundings, but she has a headache and light is bothering her. She scored a 19 on the Standardized Assessment of Concussion (SAC) (where 25 or above is considered normal). She is sent home with her parents who were counseled on concerning symptoms to watch for throughout the weekend.
On Monday, the patient returns and reports having been asymptomatic since Saturday night. The athletic trainer (AT) clears her for school activities that day, which she tolerates well. On Tuesday, she is cleared for a cardio session on the stationary bike and completes it while continuing to be asymptomatic. On Wednesday, she is cleared to return to practice for running drills only. Unfortunately, while at practice, she experiences a headache and is pulled from the remainder of running drills. The next day, she drops back down to a cardio session on the stationary bike, which she tolerates without symptoms, and is then cleared by her ATC to try running drills again after a 24 hour period of being asymptomatic.
The second time she returns to practice for running drills, she remains asymptomatic and is then is cleared to progress in the concussion return to play protocol. The day after tolerating running drills, she is allowed to join the team resistance training session with light weights and soccer passing drills with no contact. Next steps will be joining a full practice with no restrictions, and then finally, a full game.
A concussion is defined as trauma to the brain caused by rapid acceleration that can consist of axonal damage, cerebral inflammation and changes in blood flow. Its symptoms can range from asymptomatic to severe and the most important elements of its treatment are cognitive and physical rest, rather than surgery and medicines (1). Approximately 3.8 million sports and recreation related concussions occur in the United States each year, with almost 2 million of those occurring in children and adolescents under the age of 18 (1). Due to the risk of possible re-injury and/or long term neurocognitive damage if a concussion is not managed properly, it is important that athletes follow a stepwise return to play protocol that is managed by a healthcare professional who has concussion expertise.
While this chapter will focus on a concussion return to play protocol for athletes, any child or adolescent who experiences a concussion by any mechanism should follow similar guidelines in management relative to neurocognitive rest and a graduated program toward more strenuous physical activity.
When there is suspicion for a head injury, the athlete should be pulled from play immediately to be assessed for a concussion or any serious trauma. Symptoms and signs of concussion are varied and can include but are not limited to headaches, fatigue, vision changes, light or noise sensitivity, vestibular symptoms of dizziness, balance problems, nausea/vomiting, or blurred vision, cognitive symptoms of confusion, difficulty concentrating, memory problems, or feeling in a fog, and emotional and psychological symptoms, such as irritability, sadness, anxiety, and trouble sleeping. If the injured player exhibits any concussion symptoms or signs, they should not return to physical activity that day under any circumstance. The phrase "when in doubt, sit them out", should be emphasized in situations where it is unclear whether the athlete has sustained a concussion or not. Neurocognitive and physical rest are the most important primary interventions for concussion management in the first 24 to 48 hours after injury. Alongside this rest, parents should be counseled on what to expect during concussion recovery, focusing especially on the signs and symptoms of a concussion, potential effects on cognition, ways to support and assist their child, and the typical duration of recovery for their child’s age (2). Concussions do not always show immediate clear outward signs of injury, making it sometimes tempting for the patients and those around them to encourage a return to activity quickly. Each person will have a different recovery course, and it is important that parents, coaches, teachers, teammates, and friends of the patient understand this, and do not push them to return to activity any sooner than they are cleared by a trained healthcare provider (3).
Due to increased brain vulnerability after a concussion, it is important that the patient follows all recovery protocols. During this time, a patient can experience worsening symptoms, further concussions, and catastrophic outcomes, such as cerebral hemorrhage or second impact syndrome (SIS) if another head injury occurs (1). SIS is rare, but can be fatal due to rapid edema, increase in intracranial pressure and herniation after a second head injury before the first is able to heal. Current evidence suggests the first 7 to 10 days after head injury are the greatest risk for reinjury (1).
Cognitive rest requires that any activity that worsens symptoms should be minimized for the first few days. This includes activities such as electronic media screen time, social visits, and interactions, as well as homework, and studying. Allowing extra rest, napping or greater night time sleep, and rest from school, may be helpful for the first 24 to 48 hours. However, it is important not to keep a child away from cognitive engagement for too long post-concussion (2). As soon as a patient can tolerate 30-45 minutes of concentration without exacerbation of symptoms, they should return to school work (4). Students who are asymptomatic or have low-level symptoms may return to school immediately after a concussion. While one to two days of rest are often beneficial, students should not miss more than 2 to 3 days of school in order to stimulate brain recovery and to mitigate the harm of a prolonged absence from school (4). If symptoms are still significant after 2 to 3 days, consider half-day school attendance and academic accommodations to allow school participation while managing symptoms. When returning, physicians or other healthcare professionals should contact the school and arrange for accommodations if the student becomes symptomatic. These academic adjustments are temporary until the patient feels well and includes accommodations such as reduced workload and assignments, extended deadlines for assignments, extended time for quizzes and tests, taking a brief rest in the nurse’s office, having reduced class time during their first days back, postponing tests, or having assistance in the classroom (e.g., providing a note taker) (7). The concussed student should be moved to a seat in the front of the classroom where the teacher can assist them and note if they are experiencing any difficulties (7).
A 24 to 48 hour period of physical rest is recommended immediately following a concussion. Thereafter, current evidence suggests that light noncontact aerobic exercise is beneficial to healing and should be started but monitored so as to not exacerbate any symptoms. Participation in light noncontact exercise is encouraged, even with mild symptoms, as long as it does not provoke new or exacerbate existing symptoms. This initiation of sub-symptom threshold aerobic exercise, such as walking or stationary biking, has been shown to hasten recovery and prevent deconditioning (5,6).
Within the first few days, pharmacologic treatment of symptoms can be initiated but should not be used as a way to mask symptoms to further progress through recovery or as an attempt to return to play more quickly (2). Acetaminophen or NSAIDs may be appropriate for treating headaches. For concussion patients with a pre-existing history of migraine headaches, abortive therapies for those experiencing migraines may be used. Antiemetics can be used for nausea but can cause side effects that may worsen other concussion symptoms and should be stopped if this is the case. After the first few days, pharmacologic interventions are not typically needed or advised. If a patient is still experiencing worsening symptoms after a 48 hour period of cognitive and physical rest, a further evaluation should be completed with a trained medical provider (2). Concussion patients are encouraged to continue their pre-existing medication regimen for any historical condition, for example, attention deficit hyperactivity disorder or anti-depression medication.
Other helpful measures to assist the concussed patient in symptom management include an emphasis on proper nutrition and hydration, sleep hygiene, stress management, screen time limits guided by symptoms, and a return to baseline lifestyle routines as much as feasible. A nutritious diet with water hydration, eating healthy snacks as needed, and regular mealtimes can be helpful. Focusing on an age-appropriate bedtime and avoiding daytime napping after the first week also allows for a return in a well-rested state. Screen time does not have to be eliminated but should be reduced as needed to limit symptom exacerbation.
Once the 24 to 48 hour resting period has elapsed, and light aerobic exercise has commenced, a student athlete may make their way through the rest of the return to play protocol granted the following conditions are met: the student has returned to school successfully, they are symptom free without the use of pharmacologic interventions for at least 24 hours, they have a normal neurologic exam, and they are back at baseline balance and cognitive measures. There should be a 24 hour period between each stage in which the athlete remains asymptomatic before being able to progress. If at any point symptoms return, the athlete needs to return to the previous stage (see table 1) and remain asymptomatic for 24 hours before attempting to progress again. (2)
Table 1 – Stages of concussion recovery (2)
If a computerized neuropsychological test was performed at baseline, such as ImPACT (Immediate Post-Concussion Assessment and Cognitive Test), SAC (Standardized Assessment of Concussion), or vestibular screening such as Sway balance testing, an athlete should continue to use the test throughout the recovery period as instructed, and a return to practice should not be allowed until a return to baseline scores is attained (2,7).
Concussion management requirements vary by state and by school district, and the clinician should be aware of these differing restrictions. Specific policies may include a required number of symptom free days before returning to play, or an equal number of asymptomatic days as symptomatic (2).
Most athletes become asymptomatic and are cleared to play within a month from the date of injury; however, it is important to remember that each patient recovers differently, and each concussion management plan will need to be individualized, progressive, and gradual (2). If post-concussion symptoms last longer than 21 days despite sufficient cognitive and physical rest, a sports medicine specialist, physiatrist, or neurologist should be consulted. A consultation should also be obtained if the patient has had 3 or more concussions over their lifetime, multiple concussions that are sequentially increasing in symptom severity, increasing recovery duration, or if a diagnosis of concussion is uncertain (2).
While the prognosis for concussion recovery is good, it is important that all patients are compliant with a stepwise return to activity to avoid any complications. Prolongation of symptoms can occur when attempting to return too quickly, and more serious complications, such as Second Impact Syndrome or long-term sequelae, or chronic traumatic encephalopathy (CTE) may occur if a patient receives more injuries to the head without being fully recovered from their initial concussion (8). Hence, concussion education for proper recognition and management of head injury is critically important for both the patient, as well as the people who surround them, such as parents, educators, coaches, and peers.
Questions
1. True/False: A patient can return to play on the same day after obtaining a concussion as long as they are asymptomatic for 2 hours.
2. True/False: If a student athlete continues to have a headache on the fourth day after sustaining a concussion, can they engage in light aerobic exercise?
3. How long must a student athlete be asymptomatic in the return to play protocol before progressing to the next stage?
4. True/False: If a patient attends their first noncontact practice and experiences concussion symptoms, they should try to attend practice the next day and hope that their symptoms do not return.
5. True/False: The athlete is the only one who needs to understand the importance of a full recovery after a concussion.
References
1. Halstead ME, Walter KD, Moffatt K. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2018;142(6):e20183074. doi: 10.1542/peds.2018-3074
2. Meehan WP III, O’Brien MJ. Concussion in children and adolescents: Management. UpToDate 2022. -- It appears that Anela has changed this #2 to: 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. Br J Sports Med 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898
3. Meehan WP III. Medical therapies for concussion. Clin Sports Med. 2011;30:115-124. doi: 10.1016/j.csm.2010.08.003
4. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132(5):948-957. doi: 10.1542/peds.2013-2867
5. Leddy JL, Haider MN, Hinds AL, et al. A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med. 2019;29(5):353-360. doi: 10.1097/JSM.0000000000000663
6. Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med. 2017;51(12):949-957. doi: 10.1136/bjsports-2016-097415
7. Dessy AM, Yuk FJ, Maniya AY, et al. Review of Assessment Scales for Diagnosing and Monitoring Sports-related Concussion. Cureus. 2017;9(12):e1922. doi: 10.7759/cureus.1922
8. Rivara FP, Tennyson R, Mills B, et al. Consensus Statement on Sports-Related Concussions in Youth Sports Using a Modified Delphi Approach. JAMA Pediatr. 2020;174(1):79-85. doi: 10.1001/jamapediatrics.2019.4006.
Answers to questions
1. False. When there is suspicion for a head injury, the athlete should be pulled from play immediately to be assessed for a concussion or any more serious trauma. If they have any concussion symptoms, they should not return to physical activity that day under any circumstance and should not return until cleared by a trained medical professional.
2. True. After a 24 to 48 hours rest window, studies show that light aerobic exercise should be started, but monitored so as to not exacerbate any symptoms. This initiation of sub-symptom threshold aerobic exercise, such as walking, has been shown to hasten recovery and prevent deconditioning.
3. 24 hours
4. False. If at any point, symptoms return, the athlete needs to return to the previous stage where they had been symptom-free and they must remain asymptomatic for 24 hours before attempting to progress again.
5. False. Each person will have a different recovery course, and it is important that parents, coaches, teachers, and friends of the patient understand this, and do not push them to return to activity any sooner than they are cleared for by a healthcare provider.