Return to Play after Concussion

1. See Also
   1. Concussion Grading
   2. Concussion
2. 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
3. Management: Graded Return to Play
   1. Indications to start
      1. Symptom-free and
      2. Medication-free
   2. Protocol
      1. Follow step-wise approach with no less than 24 hours between steps
      2. 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. Non-impact aerobic Exercise
      2. Sport-specific Exercise (non-impact drills)
      3. Non-contact training drills
      4. Full contact practice
      5. Return to normal play
4. Management: General Guidelines
   1. See Management of Mild Head Injury
   2. These guidelines are older and time intervals for return to play are more variable
      1. See Concussion
      2. Return to play should follow the Graded protocol above
   3. Based on three separate and conflicting guidelines
      1. Cantu Guidelines (1986)
      2. Colorado Medical Society (1991)
      3. American Academy of Neurology (1997)
   4. Definition of Asymptomatic (guidelines below)
      1. No somatic symptoms
      2. No behavioral symptoms
      3. No cognitive symptoms
5. Management: Guidelines for Grade 1 Concussion
   1. Background
      1. Grade 1 Concussion memory deficits persist 1-6 days
      2. Return to play in 15 minutes may be too soon
      3. Lovell (2004) Am J Sports Med 32:47-54
   2. First Grade 1 Concussion
      1. Athletes should not return to play on same day of Concussion (even first Grade 1 Concussion)
      2. Prior guidelines suggested return to play if asymptomatic for 15-20 minutes
         1. Exception may be professional athletes if adequate sideline evaluation
   3. Second Grade 1 Concussion
      1. Requires formal examination by physician
      2. Return to play if asymptomatic for 1 week
   4. Third Grade I Concussion
      1. Terminate season
      2. Requires formal examination by physician
6. Management: Guidelines for Grade 2 Concussion
   1. First Grade 2 Concussion
      1. Requires formal examination by physician
      2. Return to play if asymptomatic for 1 week
   2. Second Grade 2 Concussion
      1. Return to play if asymptomatic for 1 month
   3. Third Grade 2 Concussion
      1. Terminate Season
7. Management: Guidelines for Grade 3 Concussion
   1. First Grade 3 Concussion
      1. Urgent Neurologic Exam at hospital ER
      2. Consider Head CT
      3. Return to play guidelines
         1. No participation for one month minimum
         2. May return to play if asymptomatic for 1-2 weeks
   2. Second Grade 3 Concussion
      1. Terminate Season
   3. Third Grade 3 Concussion
      1. Terminate Sport
8. References
   1. Kushner (2001) Am Fam Physician 64:1007-14
   2. Whiteside (2006) Am Fam Physician 74(8):1357-62
   3. Scorza (2012) Am Fam Physician 85(2): 123-32
   4. Putukian (2011) Clin Sports Med 30(1): 49-61
   5. Patel (1010) Pediatr Clin North Am 57(3): 649-70
   6. Hunt (2010) Clin Sports Med 29(1): 5-17