Return to Play After Concussion Is Step-By-Step Process

According to the most recent international consensus statement on concussion in sport, return to play (RTP) after a child or teen suffers a sport concussion should be a step-by-step, graduated, exercise-limited, process which can begin after an initial period of 24-48 hours of both relative physical and cognitive rest:

• 24 hours between steps: Generally, each step should take at least 24 hours, so that, assuming the athlete does not experience a recurrence of concussion symptoms at rest or with exercise as she progresses through the exercise program, she will be able to return to sports in about a week’s time after symptoms have cleared.   
• Fall back if symptoms return: If the student-athlete experiences a recurrence of concussion symptoms during any of the steps, they need to drop back to the previous level at which they were symptom-free, and try to progress again after a further 24-hour period of rest has passed.
• 7-day waiting period before beginning in absence of neurocognitive testing. In the absence of daily testing by a healthcare professional with concussion expertise (certified athletic trainer, school/team/primary care/sports medicine physician, neuropsychologist) to clear a student-athlete to begin the graduated return-to-play protocol, a student-athlete should observe a 7 day rest/recovery period before commencing the protocol. This means that, for such athletes, return to sports will take at least two weeks. Some leading concussion experts, including Dr. Rosemarie Scolaro Moser, a sports concussion neuropsychologist featured in the MomsTEAM PBS documentary, The Smartest Team: Making High School Football Safer, recommend that children and adolescent take a minimum of three weeks off before returning to sports after a concussion.  

State laws on return to play vary

According to data released in March 2016 by the National Athletic Trainers’ Association, 44 percent of states now require that a graduated return-to-play protocol consisting of at least five steps (with no more than two steps occurring on one day) is implemented for athletes returning back to activity from a concussion, which is a 24 percent improvement from the 2014-2015 school year.  

California recently became the first state to mandate a minimum 7-day waiting period after a concussion before a return to sports for interscholastic athletes, and to require the successful completion of a graduated return-to-play exercise protocol supervised by a healthcare professional which can only begin once a student-athlete is no longer experiencing concussion symptoms.

While many of the youth sports concussion safety laws passed by the states since 2009 contain broad language allowing any “qualified healthcare professional” to make the return-to-play decision, studies show that many primary care physicians (10) lack the expertise required to make return to play decisions.  Because they have more training and experience in concussion diagnosis and management, certified athletic trainers, team doctors, and neuropsychologists are usually the best qualified to decide when it is safe for an athlete to return to play.

Experts caution that, while an estimated 80 to 90% of concussions heal spontaneously in the first 7 to 10 days, children and adolescents may require a longer rest period and/or extended period of non-contact exercise than adults, because their developing brains cause them to experience a different physiological response to concussion than adults and take longer to recover, and they have other specific risk factors, such as the risk of second impact syndrome.

A number of recent studies suggest that concussed adolescents, perhaps even more than younger and older athletes, take longer to recover full cognitive function and should be held out of play longer. One study found that concussed adolescents have difficulty recovering the ability for high level thinking after injury and may require extended recuperation before full recovery of so-called ‘executive function’ is achieved, with researchers at the University of Oregon and University of British Columbia finding that executive function was disrupted in concussed adolescents for up to 2 months after injury when compared to healthy control subjects. 

Non-compliance is serious problem

In their desire to return to the playing field, however, some high school athletes fail to comply with return-to-play guidelines.  A 2009 study (4) by researchers at Nationwide Children’s Hospital in Columbus, Ohio, for example, found that at least 40.5% and 15.0% of athletes who sustained concussions returned to play prematurely under the now-outdated American Academy of Neurology (AAN) and then current Zurich return-to-play guidelines.  

A 2011 study however, showed for the first time the important role computerized neuropsychological testing is playing in concussion assessment and RTP decisions. Athletes who had taken a pre-season, baseline ImPACT computerized neuropsychological test, and took the ImPACT test again after suspected concussion were less likely to return to play on the same day, and less likely to return to play within a week of their injury, than the three out of four injured athletes who did not undergo such testing.

The authors suggested three possible reasons:

1. that the computerized tests are more reliable in gauging whether an athlete’s cognitive functioning had returned to baseline than self-reporting by athletes of signs and symptoms (which, in the interest of a quick return to play, an athlete may downplay or fail to report altogether)(a hypothesis which was confirmed in a more recent study; 
2. that the use of such tests by those providing concussion management leads them to be more conservative in return-to-play decisions; and
3. that neurocognitive testing is used more often in cases of severe concussions that require extended recovery times before return to play.

Post-exercise neurocognitive testing recommended

A 2013 study of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated return to sports protocol, found that more than a quarter (27.7%) exhibited declines in verbal and visual memory on the tests after moderate exercise. 

The findings prompted sports concussion neuropsychologist Neal McGrath, Ph.D. of Sports Concussion New England and his colleagues to recommend that neurocognitive testing become an “integral component of the athletic trainer’s post-exertion evaluation protocol and that student-athletes should not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on such post-exertion neurocognitive concussion testing.”

“Given the unreliable nature of self-reported symptoms in athletes, a group typically motivated to return to play and minimize symptoms, the sensitivity of computerized neurocognitive testing to incomplete recovery and the importance of identifying any indicators that an athlete may not remain stable in his/her baseline functioning prior to return to contact sports action, post-exertion neurocognitive testing appears to be a logical tool to consider.” 

“Our thinking,” said McGrath, “is that since exercise is known to cause recurrence of symptoms in some athletes who may not be fully recovered, and since neurocognitive testing has been shown to reveal persisting cognitive deficits in athletes who say or feel that they are symptom-free (6) any significant decline in post-exercise cognitive test scores for those athletes who have reached the point of feeling fully symptom-free, with resting neurocognitive scores that are back to baseline, would indicate that more recovery time is needed before returning to contact sports action. We would follow those athletes until their post-exercise neurocognitive test scores remain stable at baseline levels before clearing them to return to play.” 

As young athletes tend to consider only a small subset of their potential symptoms when reporting their recovery or saying they are “back to normal” after concussion (6) caution is urged in considering athletes’ self-reported symptoms in their return-to-play decisions, and the same caution is warranted in relying solely on neurocognitive test scores having returned to normal before the graduated exercise protocol is begun.

Indeed, a recent study of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated exercise protocol, found that more than a quarter exhibited declines in verbal and visual memory on the tests after moderate exercise, prompting a recommendation that student-athletes not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on neurocognitive concussion testing performed after the exercise protocol is begun. While this was only one study, additional post-exercise neurocognitive testing may eventually become an important part of the RTP protocol.

* This is a significant change from the RTP protocol recommended in previous consensus statements, all of which recommended that athletes rest until they became symptom-free before beginning the graduated exercise protocol.

1. McCrory P , Meeuwisse W , Dvořák J , et al  Consensus statement on concussion in sport-the 5th International conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838–47.doi:10.1136/bjsports-2017-097699

2. Halstead, M, Walter, K. Clinical Report – Sport-Related Concussion in Children and Adolescents.  Pediatrics 2010;126(3):597-615.

3.  Meehan W, d’Hemecourt P, Comstock D. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

4.  Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005-2008.  Brain Inj. 2009:23(11):888-98.

5. Lincoln A, Caswell S, Almquist J, Dunn R, Norris J, Hinton R. “Trends in Concussion Incidence in High School Sports: A Prospective 11-Year Study”Am. J. Sports Med.accessed January 31, 2011 @http://ajs.sagepub.com/content/early/2011/01/29/0363546510392326.

6. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012).

7. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics DOI: 10.1016/j.jpeds.2012.04.012 (in press).

8. Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR. et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance.  J Athl Tr. 2008;43:265-274.

9. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP.  Post-exertion neurocognitive test failure among student-athletes following concussion.  Brain Inj 2013;27(1):103-113.

10.  Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric Providers’ Self-Reported Knowledge, Practices, and Attitudes About Concussion. Pediatrics 2012;130(6). DOI: 10.1542/peds.2012-1431)(published online ahead of print)(accessed November 19, 2012)

11. Howell D, Osternig L, Van Donkelaar P, Mayer U, Chou L.  Effects of Concussion on Attention and Executive Function in Adolescents.  Med Sci Sports Exer. 2013;45(6):1023-1029.