Playing With Concussion Doubles Recovery Time For High School Athletes

High school athletes who continue to play with a sport-related concussion (SRC) take nearly twice as long to be cleared for a full return to sports than those who are immediately removed from play, finds a new study published in the journal Pediatrics. (1)

Analyzing data collected prospectively on a group of 69 high school athletes seen at the University of Pittsburgh Medical Center Sports Medicine Program during a three-month period in fall 2014 after suffering a diagnosed concussion playing one of eight contact or collision sports, researchers found that the 34 athletes who kept playing:

were 8 times more likely to take 21 days or longer to receive medical clearance for full sports participation after concussion than the 35 athletes who were immediately removed from play after injury;
took an average of 44 days from injury ± 36 days to medical clearance, compared to 22 days ± 18.7 days for the removed group; and
performed significantly worse on tests of verbal and visual memory, processing speed, and reaction time, and reported more severe concussion symptoms, both at their initial and follow-up visits than those in the removed group.

The findings, said the authors, provided strong support for using removal-from-play status as a factor in predicting protracted recovery from SRC.

Our results “underscore the risks associated with continuing to play with an SRC,” said lead author R.J. Elbin, director of the Office for Sport Concussion Research at the University of Arkansas, who performed the research while at the University of Pittsburgh. Elbin and his colleagues recommended that the findings be incorporated into SRC education and awareness programs for athletes, coaches, parents, and medical professionals emphasizing the importance of timely recognition and/or identification of the signs and symptoms of SRC’s and immediate removal from play.

The findings were generally consistent with those in a retrospective study reported in the Journal of Athletic Training in May 2016 (2) involving a group of NCAA Division 1, mostly football, athletes which likewise found a strong association between delayed reporting of concussion symptoms and prolonged recovery.

That study, by researchers at the University of Florida and and the Medical College of Wisconsin, linked delayed reporting of concussion symptoms with a recovery almost 5 days longer than for athletes who immediately reported symptoms, and found that athletes who delayed reporting were approximately 2.2 times more likely to experience a prolonged recovery of 8 days or more. Of the concussed athletes immediately removed from play, 73% recovered in one week and all recovered by two weeks. By contrast, of those who delayed removal from play only 40% recovered by one week, and at two weeks 20% were still symptomatic.

The importance of immediate removal from play following a sports-related concussion in protecting athletes from re-injury was also shown in a third 2016 study which found that adolescent athletes who sustained an additional head impact within 24 hours of a sports-related concussion (SRC) experienced more severe symptoms and took significantly longer to recover. (3)

Motivational Tool

Taken together, the three studies have important implications for clinicians, who will now be able to say to concussed athletes who did not come out of the game right away after experiencing symptoms that their recovery might take much longer as a result.

It is their use, however, in helping to motivate athletes to get checked out as soon as they begin experiencing symptoms after a big hit, and in changing a sports culture that expects athletes to hide symptoms in order to keep playing, that may be their greatest significance.

Among the reasons athletes give for not immediately reporting concussion symptoms are a belief that they can safely delay disclosure until their removal is less likely to affect game or practice play, or until the symptoms worsen and can no longer be ignored. (2)

“From a pragmatic perspective, we believe [our findings show] that immediately reporting concussion symptoms is [actually] in the best interests of teammates and coaches,” says lead author of the JAT study , Breton Asken, because “it is likely more beneficial for the team if the athlete misses the shortest amount of time possible after sustaining a [concussion]” and “overall performance is not compromised by the concussion.”

“If athletes know that they may be worsening their recoveries by failing to report concussions, they may have incentive to properly disclose suspected injuries in a timely manner,” Asken suggests.

In comments on the Pediatrics study to The New York Times (4), Elbin echoed Asken, arguing that the findings could help promote the message that taking immediate precautions after concussion would actually allow athletes more opportunities to keep playing, not fewer. “It’s something we consistently preach to coaches, parents, and kids,” Elbin said, but until now there “really has not been any [supporting] data.”

Badge of honor

The findings of the two studies came as no surprise to Andrew M. Blecher, a primary sports medicine physician at the Southern California Orthopaedic Institute. “From the moment an athlete tells me that they kept playing after the hit, or they didn’t tell anyone, or they finished the game, or they played two more games, I know the athlete is going to be in for a long recovery. These are the athletes who take weeks to months to recover.”

What these two new studies show, says Blecher, is that, “if you want to get back to playing as soon as possible, if you really want to do what is best for yourself and for your team, if you really want to recover as quickly as you can, then you need to give your brain immediate rest and recovery.”

To athletes who keep playing with concussion symptoms instead of getting checked out because they do not want to disappoint coaches, teammates, parents, and fans by coming out of the game, Blecher says, “Your teammates and coaches should be disappointed in you for trying to hide your symptoms. They should not be proud that you tried to play through [the injury]. They should also be disappointed in themselves for not recognizing the signs earlier. You need to keep an eye on each other and report when you see a teammate acting abnormally, when something’s not right.”

Blecher urged athletes, for the good of the team, to pledge at the beginning of the season to report their own and each other’s concussion concerns, to be vigilant about reporting, and to wear honest reporting “as a badge of honor. “This is the culture that we need. This is what is best for the team and for each and every athlete that steps on the field.”

Immediate rest is best

”This new study by Elbin and colleagues confirms what we have been saying for years: that immediate rest following concussion helps recovery, ” said Rosemarie Moser, Director of the Sports Concussion Center of New Jersey, who noted that a failure to rest immediately after injury had been shown in animals to delay recovery (5), and in research of hyperactivation on brain MRI for those high school students who did not rest following concussion. (6)

“In a competitive, stimulus-seeking culture that does not rest, and that is often sleep deprived, [it is unfortunate that] we prefer to continue with activity rather than allow for a rest or down period. It is difficult to even find time for that brain rest when we are constantly plugged into cell phones, computers, iPADs, Kindles, texting, Facetime and Facebook in our “free time.’ With such an attitudinal framework, one can understand why athletes might not report concussion and just choose to play through the game,” said Moser.

Elbin RJ, Sufrinko A, Schatz P, French J, H Luke, Burkhart S, Collins MW, Kontos AP. Removal From Play After Concussion and Recovery Time. Pediatrics 2016;138(3):e20160910 (epublished August 29, 2016); DOI:10.1542/peds.2016-0910.
Asken BT, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. “Playing Through It”: Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Ath Tr. 2016;51(5):000-000. doi: 10.4085/1062-6050-51.02 (epublished ahead of print May 2016).
Terwilliger VK, Pratson L, Vaughan CG, Gioia GA. Additional Post-Concussion Exposure May Affect Recovery in Adolescent Athletes. J Neurotrauma 2016;33(8): 761-765. doi:10.1089/neu.2015.4082.
Rachel Rabkin Pechman. “Playing With a Concussion Doubles Recovery Time.” New York Times. August 29, 2016. http://www.nytimes.com/2016/08/29/well/move/playing-with-a-concussion-doubles-recovery-time.html (last accessed August 30, 2016)
Griesbach et al. Animal model: voluntary exercise in concussed rats may delay recovery if administered too soon following TBI. Neurosci 2004 (accessed at http://www.ncbi.nlm.nih.gov/pubmed/1505115 2)
Lovell et al. In high school athletes, hyperactivation on fMRI during first week predicted prolonged clinical recovery. Brain activation immediately following a concussion may result in longer period of symptoms. Neurosurg. 2007 (accessed at http://www.ncbi.nlm.nih.gov/pubmed/17762748)

Updated September 1, 2016 to include Dr. Moser’s comments; further updated September 5, 2016 to include a discussion of the study cited in n. 3.