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The Facts About Returning to Play After a Concussion

Updated on February 27, 2014

Disclaimer

This article is neither meant to replace nor act as medical advice. It is merely presenting supplemental information to help you understand the safe return to play process based on the recommendations from Consensus Statement on Concussion in Sport: The 4th International Conference on Concussion in Sport, Zurich, November 2012.

The Quick View

  • More information about concussions in general can be found here.
  • If you have a concussion, STOP READING. Rest is your ally.
  • There are 5 stage of returning to play.
  • Any presentation of symptoms means the injured in not ready to move on.

Muddy Waters

Determining a return to play date is a difficult decision for physicians and athletic trainers. It is not as cut and dry as determining a return to play from ACL surgery or ankle sprain where the damage is visible. The biggest challenge is relying on the athlete reporting symptoms. It's not uncommon for an athlete at any level to try and hide symptoms from coaches, parents, and athletic trainers. Most athletes don't understand the ramifications of trying to play through a concussion. Second-impact syndrome is a dangerous condition where the brain actually swells rapidly and ends, usually, with death.

This article is not meant to scare anyone away from playing sports. This article merely states the facts about return too soon from a concussion. This is based on a general Return-to-Play protocol. Your school or team may have a different version. Please follow their direction.

Time to Recover

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Stage 0:The Concussive Blow

Day 0 is the day of the injury. It can happen from playing football, soccer, or tripping on the sidewalk. It doesn't matter how the concussion happens, it happened and nothing can change the past, Doc.

The important thing to do on this first day is to monitor symptoms. If the symptoms get worse then you need to take the injured to the emergency room. It is not recommended to take any form of pain reliever in the first 24 hours unless otherwise directed by a physician. This could mask the symptoms and create complications. The worst thing to take would be ibuprofen or aspirin, these are blood thinners and could exacerbate bruising or bleeding in the brain. A brain bleed (both subdural and epidural hematomas) is rare outside of a major car accident or other very significant blow to the head. See Head Injury Precautions below.

It is unnecessary to wake the affected person as long as the symptoms have normalized. Sleep is one of the best treatments for a concussion. Rest from activity and other external stimulus is needed to aid in recovery. If the injured starts to develop a headache when watching tv, texting, reading, or even light and/or sound in general, that activity needs to stop.

The best analogy I can give is equating the development of a headache with an activity when you have a concussion is like trying to run through pain with a sprained ankle. You are not helping yourself or the team by trying to be tough.

A brief Summary of a Concussion

The above video is a fantastic summary of everything that is discussed in this article. The doctor uses slightly different terms and quotes slightly different research but, all the basics are the same.

Stage 1 RTP: Symptom Resolution

There is no specific end date in this section. Symptoms can resolves within a day or two. Symptoms can also last weeks or months as another condition called Post-Concussion Syndrome (more on this topic in a future hub). Briefly, post-concussion syndrome (PCS) is a lasting set of symptoms generally treated by a specialist. Approximately 10-15% of people suffer from PCS.

To aid with recovery, the injured should continue to refrain from any activity that exacerbates symptoms. If reading increases a headache, reading should stop. This goes for texting, watching television, even being around bright lights. A quiet dark room is usually the optimum way to promote recovery and healing.

It might be beneficial to miss a day or two of classes. If symptoms persist the injured is not retaining the information presented in class. The foggy feeling inhibits learning. Speak with a school nurse and find out if the school has a concussion protocol. Some school inform the student's teachers about the concussion. Tests and assignments can be rescheduled so the student does not miss out or fall behind.

When the injured is able to exert himself or herself cognitively then, he or she is ready to progress to Day 1 RTP (Return-to-Play). If applicable this may include a paper or computer based neuropsychological test such as ImPact.

Light Aerobic Activity

Light aerobic activity can include biking, swimming, and jogging.
Light aerobic activity can include biking, swimming, and jogging. | Source

Stage 2 RTP: Light Aerobic Activity

After the symptoms have resolved activity should slowly be introduced in a controlled setting. A controlled setting could mean the shallow end of the pool for swimming, running on a treadmill or track, or riding a stationary bike.

The goal for this stage is to increase the heart rate to no more than 70% of your maximal heart rate. A quick and easy estimation is 220 - age = Max Heart Rate. We want to get the blood pumping in this stage for about 20 to 30 minutes. If any symptoms begin to show, stop immediately. Your brain is not ready for activity and you should not try to exercise again for at least 24 hours.

If you do not have any symptoms that show up during or after the exercise, you are ready to move on to the next stage. You are not allowed to complete more than one stage in a 24 hour period. If you have any symptoms during activity or in the next 24 hours you are not allowed to move on.

Sport Specific Exercise

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Stage 3 RTP: Sport Specific Exercise

After completing Stage 2 and waiting 24 hours, you can move on to Stage 3.

This is where you can participate in sport specific exercise. If you are a hockey player this means you can skate and only skate. A football player can put on shoulder pads and a helmet and participate in the warm-up. In soccer this mean you can participate in running drill. No head contact should happen in any drill at this point.

The goal in this stage is to increase the heart rate further and begin to challenge the injured mentally by increasing the difficulty of the task.

If you do not have any symptoms that show up during or after the exercise, you are ready to move on to the next stage. You are not allowed to complete more than one stage in a 24 hour period. If you have any symptoms during activity or in the next 24 hours you are not allowed to move on.

Noncontact Drills

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Stage 4 RTP: Noncontact Drills

After completing Stage 3 and waiting 24 hours, you can move on to Stage 4.

The goal of this stage it to further increase the mental tax on the athlete, coordination, and maintain an increased heart rate level. The athletes can participate in many of the drills further preparing them for returning to sports. Again, the athlete is not ready for contact. Adding head contact drills could further delay recovery time.

If you do not have any symptoms that show up during or after the exercise, you are ready to move on to the next stage. You are not allowed to complete more than one stage in a 24 hour period. If you have any symptoms during activity or in the next 24 hours you are not allowed to move on.

Stage 5 RTP: Full Contact Practice

After completing Stage 4 and waiting 24 hours, you can move on to Stage 5.

The goal of this stage is to restore confidence with the athlete, coaches, and parents. The athlete is allowed to fully participate in practice with no restrictions. At this point the coaches can assess the readiness of the athlete to participate in competition.

The athletic trainer and/or physician are also assess the player readiness to return based on physical performance and any reported symptoms.

If you do not have any symptoms that show up during or after the exercise, you are ready to move on to the next stage. You are not allowed to complete more than one stage in a 24 hour period. If you have any symptoms during activity or in the next 24 hours you are not allowed to move on.

Head Injury Precautions

This is a copy I hand out to all of my head injury athletes. Whether or not I have assessed them as having a concussion, I hand them one of these form to give to their parent(s).

During the first 24 hours:

  1. Diet – drink only clear liquids for the first 8-12 hours and eat reduced amounts of foods thereafter for the remainder of the first 24 hours.
  2. Pain Medication – DO NOT take any pain medication unless specifically directed and prescribed by a physician.
  3. Activity – activity should be limited for the first 24 hours; this would involve no school, videogames, extracurricular physical activities or work when applicable.
  4. Driving – The sports medicine staff, based on national guidelines and position statements, strongly recommends that the athlete NOT drive for the first 24 hours.
  5. Observations – several times during the first 24 hours:
    1. Check to see that the pupils are equal. Both pupils may be large or small, but the right should be the same size as the left.
    2. Check the athlete to be sure that he/she is easily roused; that is, responds to shaking or being spoken to, and when awakened, reacts normally.
    3. It is unnecessary to wake the athlete during the night unless otherwise instructed.
    4. Check for and be aware of any significant changes. (See 6 below)
  6. Conditions may change significantly within the next 24 hours. Immediately obtain emergency care for any of the following signs or symptoms:
    1. Persistent or projectile vomiting
    2. Unequal pupil size (see 5.1 above)
    3. Difficulty in being roused
    4. Clear or bloody drainage from the ear or nose
    5. Continuing or worsening headache
    6. Seizure
    7. Slurred speech
    8. Inability to recognize people or places – increasing confusion
    9. Weakness or numbness in the arms or legs
    10. Unusual behavior change – increasing irritability
    11. Loss of consciousness
  7. Improvement – the best indication that an athlete who has suffered a significant head injury is progressing satisfactorily is that he/she is alert and behaving normally.

What did you learn?


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In Closing

Again, this is a general RTP and not meant as a substitute for your team or school's own RTP. Please follow their direction and guidance. This article is meant to both explain what is happening in each step and to help give guidance to those who do not have a structured RTP.

Many times parents feel left in the dark after visiting a physician because the physician writes a prescription stating they can return to full activity in a week or two. This gradual return to play helps quantify the injured's preparedness to return to activity. Hopefully this article sheds some light on the murky waters of returning to play after a concussion.

© 2014 Trainer Joe

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