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Back to school and play after a concussion

Approximately 300,000 high school athletes are diagnosed with concussion annually, and managing their return to school and sports can present a challenge for the primary care provider. Some physicians recommend cognitive rest, while others don’t, and data supporting either approach have been scant.

Guidelines and research published in the last year provide clearer recommendations. The American Academy of Pediatrics (AAP) released a clinical report titled Return to Learning Following a Concussion at its annual meeting in October 2013. Designed to provide guidance to physicians caring for adolescents after concussion, the report emphasizes cognitive rest—minimizing digital exposure and limiting studying—and a gradual return to full participation in the classroom.

Full cognitive and physical rest

A prospective cohort study, conducted at Boston Children’s Hospital and published January 6, 2014, in Pediatrics, provides critical data to support recommendations for restricted cognitive activity. Researchers reported athletes with concussions who limit high-intensity cognitive demand (which can include texting, reading and playing video games) may recover faster than those who don’t.

Boston Children’s Hospital’s Sports Concussion Clinic typically prescribes full physical and cognitive rest for a minimum of three to five days. This means eliminating all sports and exercise, and often includes staying home from school for a few days.

Return to school

Return to school is the next phase of recovery.

Boston Children’s physicians recommend a gradual re-entry into school. A detailed note to teachers that suggests they offer students a longer time for tests and projects and defer high-stakes testing can facilitate the transition and minimize stress for student-athletes.  

Return to practice and play

Athletes can start stretching and walking for exercise after the initial three-to-five-day rest period. All other exercise and sports participation should be restricted until the athlete can fully tolerate school, and symptoms (nausea, dizziness, poor concentration, amnesia) have fully resolved.

Boston Children’s Sports Concussion Clinic recommends athletes meet four criteria between returning to practice or games:

  1. full resolution of all symptoms (no headaches, dizziness, amnesia, difficulty concentrating, or double or blurry vision)
  2. academic tolerance (ability to attend school for a full day and complete schoolwork)
  3. exercise tolerance (with no lingering symptoms)
  4. cognitive testing assessment as part of the overall assessment for safe return to play

We also suggest that athletes complete a minimum of two successful practices before returning to play.

These recommendations should be tailored to the individual patient, her symptoms and clinical history. Research suggests that there is a window of vulnerability after a concussion, and that this continues even after symptoms resolve. A concussed athlete may be up to three times more likely to suffer a second concussion than an athlete who has never had a concussion.

A buffer zone between symptom resolution and return to play has value. The longer the symptom duration, the longer the period of symptom-free rest before return to play for contact sports. Some clinicians recommend an equal number of symptom-free weeks as symptomatic weeks.

When to refer to a specialist

Consider referral to a specialist if there are unusual or prolonged symptoms (beyond two to three weeks), or if there is reason to believe the athlete should never return to contact sports (multiple concussions with progressively lower threshold for injury, progressively longer recovery with successive injuries or incomplete recovery). Immediate referral to the Emergency Department should be considered if there is suspicion for associated cervical spine injury, witnessed loss of consciousness or seizure activity, progressively worsening symptoms over time or focal neurologic deficit.

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- Sandra L. Fenwick, President and CEO
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