Concussions In Sport – Return To Play
Acute Phase of the Injury
The first rule of advice is to “when in doubt, sit them out”. If a concussion is suspected by the coach, trainer, or if the athlete themselves start to describe symptoms that sound like a concussion, remove them from play. There is NO time when letting the athlete back into the game is acceptable, regardless of level of sport. German soccer player Christoph Kramer sustained a blow to the head during the FIFA World Cup final game earlier this year. The medical staff did a poor job of examining him, and he subsequently played an additional 14 minutes in the game after the injury, before he was finally removed from the game. The medical staff for Germany was heavily criticized for their poor management, which put Christoph in a position where he could have sustained a far more serious injury if he wasn’t removed from the game.
The athlete should be removed from the playing area, removed from the bench, and taken into a quiet area to conduct a concussion assessment. In the NHL this is known as the “quiet room”, where the trainers and medical staff will conduct sideline testing to determine if there is a concussion or not. Regardless of if the athlete has a negative test, if they have any symptoms that might be in the concussion realm, they will sit them out for a minimum of 24 hours.
If there is a worsening of symptoms, sending them to the hospital to rule out any red flags (serious brain injuries) will be warranted. If imaging (x-ray, CT, MRI) come back negative, then management for concussion can begin.
In the acute, post-injury phase of a concussion (24-48 hours), the only treatment is rest. This is important because a concussion is an energy imbalance in the brain, so having as much available energy to help in the recovery process is vital. However, proper sleep hygiene should be applied – no napping, and keeping their sleep consistent on weekdays and weekends. Also, unless a serious injury is suspected (which should be medically monitored anyways), it is usually unnecessary to “wake up” the athlete in increments. It just disrupts their sleep hygiene and would probably make them more moody/irritable.
Far too many times with a concussion, the athlete/individual tries to do what they normally do (TV, smart phone, computer time), and they aggravate symptoms/prolong recovery by draining their energy stores. So not only is physical rest important, but cognitive rest as well. No school, no texting, no video games/computer, no physical activity.
- Quiet music may be enjoyed (if sonophobia, aka sound hypersensitivity does not cause any issues), but not if they need to access it with a smart phone or computer.
- Visual stimulation should be minimal. A quiet, dark room is ideal, as bright light and other distractions can aggravate symptoms.
- Don’t cave – for most teenagers who go through a concussion, taking away their phone/computer/TV time will be devastating, but within their best interest.
- Remind them that in most situations, the majority of injuries will recover spontaneously over several days, and the athlete will proceed progressively through a stepwise “Return to Play” (RTP) strategy.
Concussions Return to Play
Once the individual doesn’t exhibit any symptoms, the athlete will undergo a graduated program of exercise testing. Think of weight training – athletes shouldn’t go from 0 to 100% exertion in a short time frame. It is important to take this graduated process so that it helps with physical reconditioning, and guard against symptom relapse/premature return to sport. Even though you may feel well at rest, running, jumping, or stick handling/quick cutting motions that most sports have may cause symptoms to return. Also, neurocognitive testing may be performed at this stage to help guide the rehabilitation process (the most commonly performed is the ImPact test, performed by individuals specifically trained in administering and evaluating the data). If the athlete had a baseline or pre-season concussion test done, the health care provider will be able to compare pre-injury data to post-injury data to determine if there are any deficits. If there was no baseline test done, they will compare normative baseline data to the athlete’s current values.
Table 1 below discusses the RTP protocol. You may only “graduate” from each stage if no symptoms are aggravated either during the activity or for 24 hours post exercise. This means that no athlete should return to play in less than a week. On average the process will take 6 days to 2 weeks, depending on the scenario/situation. If during ANY stage of the RTP you experience symptoms, you must drop to the previous stage for 24 hours before attempting the next stage again. Finally, medical clearance should be granted (and for some organizations, is mandatory) to return to normal game play.
Return to Learn/School
Far more importantly then return to sport, the athlete must return to school effectively as well. Going to school will challenge the brain and energy stores it has, so tasks like concentrating in class, test taking, and note taking may be a challenge. Depending on the symptoms experienced, “busy environments” might also trigger symptoms, so some circumstances might warrant the athlete to be released from class 5 minutes before the bell to avoid a busy hallway or cafeteria. Work with the teachers at the school to make sure they are aware of the situation, and if you have a health care provider managing the post-concussion issues, have them provide modifications for your child (i.e. no note taking, no tests, no physical education class, etc.) This will help with a successful return to school, and allow for a better recovery process. There are case examples of athletes who have sustained a concussion, were off sports entirely but tried to keep up their academic activities, and soon struggled with their courses because of issues with concentration, note taking, homework readings, etc. Sport should be only a portion of the individual. It’s called a student-athlete, not the other way around. Dr. Mike Evans has a great white-board video discussing this in a 10-minute video:
Post-Concussion Syndrome is a diagnosis made if an athlete’s symptoms have prolonged for longer than 3-4 weeks after an injury occurred. It is important at that stage to have proper medical assessment (or re-assessment) in order to receive the right education and management strategies for the condition. More often than not, I will push the “reset” button on patients, starting from the basics (sleep hygiene, limiting screen time, etc.), so that the brain can properly recover from the tasks the athlete does throughout the day. It’s like driving down the highway in second gear – yes, it can be done, but you are going to waste a lot of gas/energy during the drive. Concussed brains are able to do tasks, it just takes more energy to do so, and if you are not allowing adequate energy to be restored, there will be a constant state of low energy available for the tasks they are required to do.
Finally, various individuals may be called upon during the rehabilitation process, lending their expertise to the concussed athlete. Neuropsychologists, sports-physicians, physiotherapists and chiropractors are just some individuals who may help with the athlete. Performing neurocognitive tests that quantify memory and attention (like the ImPact Test), balance retraining, vestibular and motor coordination rehabilitation, cervical proprioceptive training, and cognitive behavior therapy are just a number of options available to the athlete, depending on the advice and guidance of a trained concussion management health care provider. As a health care provider, my main job/goal is to reassure the athlete and parent that symptoms over time will abate, and that with proper management and rehabilitation, the athlete should have a successful return to school and sport.