II. Precautions
- See Cognitive Deficit following Concussion
- Early return to play (especially for under age 20 years) risks Second Impact Syndrome
- Return to play should not be on the same day as Concussion
- Return to play should be based on evaluation by a medical provider
- Follow a graduated program of return to play as described below
- Guidelines are best applied to ages 13 years and older
- Athletes younger than 13 should be evaluated with greater caution
- Patient, parents and coaches should be notified of stipulations and concerns regarding return to play
- Return to play should NOT be based on the Concussion Grading System
- Graduated (stepped) plan replaces the older Return to Play after Concussion guidelines (see below)
- Return to play should not be before all symptoms and signs attributed to Concussion resolve
- Based on subjective and objective criteria below
- Return for medical reevaluation if severe or worsening Headache (esp. despite rest), persistent VomitingSeizures
- Neuroimaging may be needed
- Consider symptomatic measures
- Sunglasses (if photophobia)
- Ear plugs or noise canceling headphones (if phonophobia)
- NSAIDs for Headaches
- Avoid Analgesic Overuse Headaches
- Do not use Analgesics to allow for advancing return to play (should be truly symptom free)
III. Evaluation: Tools to monitor resolution of Concussion symptoms and signs
- Sideline: Sport Concussion Assessment Tool ( SCAT5)
- Office: Sport Concussion Office Assessment Tool (SCOAT6)
- Tools included in Standardized Assessment of Concussion (SCAT5)
- Immediate On Field Assessment
- Red Flag Symptoms (e.g. Altered Level of Consciousness, focal neurologic deficits, Seizures, Agitation, Neck Pain)
- Observable signs (e.g. Altered Level of Consciousness, neurologic deficits)
- Cervical Spine Assessment (pain at rest, active range of motion, extremity motor/sensory)
- Glasgow Coma Scale (15 points)
- Maddocks Score (5 points)
- Other testing in office, hospital or on field
- Concussion Symptom Checklist (22 points)
- Modified Balance Error Scoring System or MBess (30 points)
- Cognitive Screening of orientation, memory, recall, concentration
- Similar to Standard Assessment of Concussion
- Neuro screen exam (read aloud, cervical Neck Pain, coordination, Diplopia)
- Immediate On Field Assessment
- Other tools
- Computer based Neuropsychological Testing (e.g. ImPACT)
- In some sports, baseline testing is performed
- Baseline testing is not recommended in young children (high variability)
- Postconcussive Symptom Scale
- Computer based Neuropsychological Testing (e.g. ImPACT)
IV. Management: Graded Return to Play (and school/work)
- Indications to start
- Symptom-free and Medication-free
- See evaluation tools listed above to determine when free of symptoms, signs of Concussion
- Protocol
- Start at Step 1
- Stay at step 1 until formal sports medicine or primary care follow-up
- Follow step-wise approach with no less than 24 hours between steps
- If symptoms occur at any step
- Patient stops all activity
- When symptoms have resolved for at least 24 hours, patient may resume the current step
- Start at Step 1
- Steps
- Step 1: Physical and cognitive rest until symptom and medication free
- Goal: Recovery
- No return to play on the same day as Concussion
- Avoid cognitive activities requiring attention or concentration or that provoke symptoms
- Text messaging
- Video games
- Television
- Computer use
- School work
- Avoid physical activities that exacerbate symptoms
- Strenuous aerobic Exercise
- Weight lifting
- Household chores
- Sexual activity
- Physical and cognitive rest is typical for first 24-48 hours (symptomatic period)
- Followed by gradual Return to School and social activities
- Step 2: Transition back to school (or work)
- Notify school staff (e.g. teachers, counselors) of injury and encourage forgiveness for missed work
- Slow reintegration, allowing for scheduled breaks and rest periods
- Reduce assignments and allow for additional time to complete school work and tests
- Provide a distraction free work environment (and consider a note taker)
- Avoid standardized tests during the recovery period
- Informal accommodations are typical
- However, may consider formal individualized education plan (504 plan)
- Monitor student for first 2-3 months to identify persistent academic difficulties
- Step 3: Non-impact, light aerobic Exercise
- Start with routine daily activities that do not provoke symptoms
- First perform light activity specific to school academic work or to occupation
- Goal: Increased Heart Rate (no higher than 70% of maximum)
- Examples: Walking, swimming, stationary cycling
- Keep Heart Rate to <70% of maximum for up to 15 minutes
- Aerobic Exercise after first 72 hours post-Concussion is associated with decreased post-concussive severity and does not prolong Concussion
- Step 4: Sport-specific Exercise (non-impact drills)
- Goal: Add back sport specific movement
- Examples: Hockey skating drills, soccer Running drills
- Absolutely no head impact activities
- Keep Heart Rate to <80% of maximum for up to 45 minutes
- Step 5: Non-contact training drills
- Goal: Increase Exercise, coordination and cognitive load, advancing complexity of tasks
- Examples: Passing in ice hockey or football
- May also advance to Resistance Training
- Keep Heart Rate to <90% of maximum for up to 60 minutes
- Step 6: Full contact practice
- Goal: Confidence building and functional skills assessment by coaches
- Step 7: Return to normal play
- Step 1: Physical and cognitive rest until symptom and medication free
- References
V. References
- Bengtzen, Novak and Chesnutt (2016) Crit Dec Emerg Med 30(5): 3-10
- Hunt (2010) Clin Sports Med 29(1): 5-17 [PubMed]
- Kushner (2001) Am Fam Physician 64:1007-14 [PubMed]
- McCrory (2012) Br J Sports Med 47(5): 250-8 [PubMed]
- Putukian (2011) Clin Sports Med 30(1): 49-61 [PubMed]
- Patel (2010) Pediatr Clin North Am 57(3): 649-70 [PubMed]
- Scorza (2019) Am Fam Physician 99(7): 427-34 [PubMed]
- Scorza (2012) Am Fam Physician 85(2): 123-32 [PubMed]