II. Precautions

  1. See Cognitive Deficit following Concussion
  2. Early return to play (especially for under age 20 years) risks Second Impact Syndrome
  3. Patient, parents and coaches should be notified of stipulations and concerns regarding return to play
  4. Guidelines are best applied to ages 13 years and older
    1. Athletes younger than 13 should be evaluated with greater caution
  5. Return for medical reevaluation if severe or worsening Headache (esp. despite rest), persistent VomitingSeizures
    1. Neuroimaging may be needed
  6. Consider symptomatic measures
    1. Sunglasses (if photophobia)
    2. Ear plugs or noise canceling headphones (if phonophobia)
    3. NSAIDs for Headaches
      1. Avoid Analgesic Overuse Headaches
      2. 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

  1. Sport Concussion Assessment Tool ( SCAT5)
    1. Comprehensive - includes all other tests listed below
    2. Age 13 years old and older (SCAT5)
      1. https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
    3. Age 5 to 12 years old (Child-SCAT5)
      1. https://bjsm.bmj.com/content/bjsports/early/2017/04/28/bjsports-2017-097492childscat5.full.pdf
  2. Tools included in Standardized Assessment of Concussion (SCAT5)
    1. Immediate On Field Assessment
      1. Red Flag Symptoms (e.g. Altered Level of Consciousness, focal neurologic deficits, Seizures, Agitation, Neck Pain)
      2. Observable signs (e.g. Altered Level of Consciousness, neurologic deficits)
      3. Cervical Spine Assessment (pain at rest, active range of motion, extremity motor/sensory)
      4. Glasgow Coma Scale (15 points)
      5. Maddocks Score (5 points)
    2. Other testing in office, hospital or on field
      1. Concussion Symptom Checklist (22 points)
      2. Modified Balance Error Scoring System or MBess (30 points)
      3. Cognitive Screening of orientation, memory, recall, concentration
        1. Similar to Standard Assessment of Concussion
      4. Neuro screen exam (read aloud, cervical Neck Pain, coordination, Diplopia)
  3. Other tools
    1. Computer based Neuropsychological Testing (e.g. ImPACT)
      1. In some sports, baseline testing is performed
      2. Baseline testing is not recommended in young children (high variability)
    2. Postconcussive Symptom Scale
      1. http://www.hawaiiconcussion.com/pdf/post-concussion-symptom-scale.aspx

IV. Management: Graded Return to Play (and school/work)

  1. Indications to start
    1. Symptom-free and Medication-free
    2. See evaluation tools listed above to determine when free of symptoms, signs of Concussion
  2. Protocol
    1. Start at Step 1
      1. Stay at step 1 until formal sports medicine or primary care follow-up
    2. Follow step-wise approach with no less than 24 hours between steps
    3. If symptoms occur at any step
      1. Patient stops all activity
      2. When symptoms have resolved for at least 24 hours, patient may resume the current step
  3. Steps
    1. Step 1: Physical and cognitive rest until symptom and medication free
      1. Goal: Recovery
      2. No return to play on the same day as Concussion
      3. Avoid cognitive activities requiring attention or concentration or that provoke symptoms
        1. Text messaging
        2. Video games
        3. Television
        4. Computer use
        5. School work
      4. Avoid physical activities that exacerbate symptoms
        1. Aerobic Exercise
        2. Weight lifting
        3. Household chores
        4. Sexual activity
      5. Physical and cognitive rest is typical for first 24-48 hours (symptomatic period)
        1. Followed by gradual Return to School and social activities
    2. Step 2: Transition back to school (or work)
      1. Notify school staff (e.g. teachers, counselors) of injury and encourage forgiveness for missed work
      2. Slow reintegration, allowing for scheduled breaks and rest periods
      3. Reduce assignments and allow for additional time to complete school work and tests
      4. Provide a distraction free work environment (and consider a note taker)
      5. Avoid standardized tests during the recovery period
      6. Informal accommodations are typical
        1. However, may consider formal individualized education plan (504 plan)
      7. Monitor student for first 2-3 months to identify persistent academic difficulties
    3. Step 3: Non-impact, light aerobic Exercise
      1. Start with routine daily activities that do not provoke symptoms
      2. First perform light activity specific to school academic work or to occupation
      3. Goal: Increased Heart Rate (no higher than 70% of maximum)
      4. Examples: Walking, swimming, stationary cycling
      5. Keep Heart Rate to <70% of maximum for up to 15 minutes
    4. Step 4: Sport-specific Exercise (non-impact drills)
      1. Goal: Add back sport specific movement
      2. Examples: Hockey skating drills, soccer Running drills
      3. Absolutely no head impact activities
      4. Keep Heart Rate to <80% of maximum for up to 45 minutes
    5. Step 5: Non-contact training drills
      1. Goal: Increase Exercise, coordination and cognitive load, advancing complexity of tasks
      2. Examples: Passing in ice hockey or football
      3. May also advance to Resistance Training
      4. Keep Heart Rate to <90% of maximum for up to 60 minutes
    6. Step 6: Full contact practice
      1. Goal: Confidence building and functional skills assessment by coaches
    7. Step 7: Return to normal play
  4. References
    1. (2010) Pediatrics 126:805 [PubMed]

V. Precautions

  1. Return to play should not be based on the Concussion Grading System
    1. Graduated (stepped) plan replaces the older Return to Play after Concussion guidelines (see below)
  2. Return to play should not be on the same day as Concussion
  3. Return to play should not be before all symptoms and signs attributed to Concussion resolve
    1. Based on subjective and objective criteria above
  4. Return to play should be based on evaluation by a medical provider
    1. Follow a graduated program of return to play as described above

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