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

III. Evaluation: Tools to monitor resolution of Concussion symptoms and signs

  1. Complete tools
    1. Computerized Neuropsychological Testing (e.g. ImPACT)
    2. Sport Concussion Assessment Tool ( SCAT3)
      1. Comprehensive - includes all other tests listed below
      2. Age 13 years old and older (SCAT3)
        1. http://bjsm.bmj.com/content/47/5/259.full.pdf
      3. Age younger than 13 years old (Child-SCAT3)
        1. http://bjsm.bmj.com/content/47/5/263.full.pdf
  2. Components
    1. Concussion Symptom Checklist (22 points)
    2. Glasgow Coma Scale (15 points)
    3. Maddocks Score (5 points)
    4. Balance Error Scoring System (30 points)
    5. Finger-to-Nose Test (1 point)
    6. Standard Assessment of Concussion (30 points total)

IV. Management: Graded Return to Play

  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. 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: Non-impact, light aerobic Exercise
      1. Goal: Increased Heart Rate (no higher than 70% of maximum)
      2. Examples: Walking, swimming, stationary cycling
      3. Keep Heart Rate to <70% of maximum for up to 15 minutes
    3. Step 3: 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
    4. Step 4: 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
    5. Step 5: Full contact practice
      1. Goal: Confidence building and functional skills assessment by coaches
    6. Step 6: 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

VI. Management: Older Concussion Grading-based return to play guidelines (historical only)

  1. Precautions
    1. Use Graded Return to Play after Concussion guidelines (as above)
      1. Do not use these Concussion Grading for return to play (older, out-dated system)
    2. Concussion Grading system is shown for limited purposes
      1. Future Collision Sport exclusion
        1. Not described completely in 2012 Int. Conf. Concussion Sport consensus statement
      2. In addition, overall historical timings for return suggest an absolute minimum for return
        1. Current return to play guidelines are more restrictive, with longer delay than prior
  2. Background regarding older return to play guidelines
    1. Based on three separate and conflicting guidelines
      1. Cantu Guidelines (1986)
      2. Colorado Medical Society (1991)
      3. American Academy of Neurology (1997)
    2. Definition of Asymptomatic (guidelines below)
      1. No somatic symptoms
      2. No behavioral symptoms
      3. No cognitive symptoms
  3. Grade 1 Concussion (historical, do not use for return to play)
    1. Grade 1 Concussion memory deficits persist 1-6 days
    2. First Grade 1 Concussion
      1. Athletes should not return to play on same day of Concussion (even first Grade 1 Concussion)
      2. Elite and professional athletes should be held to same standards for return to play (not same day return)
      3. Prior guidelines suggested return to play if asymptomatic for 15-20 minutes
    3. Second Grade 1 Concussion
      1. Return to play after asymptomatic for at least 1 week
    4. Third Grade 1 Concussion
      1. Termination from Collision Sports for the season
  4. Grade 2 Concussion (historical, do not use for return to play)
    1. First Grade 2 Concussion
      1. Return to play after asymptomatic for at least 1 week
    2. Second Grade 2 Concussion
      1. Return to play after asymptomatic for at least 1 month
    3. Third Grade 3 Concussion
      1. Termination from Collision Sports for the season
  5. Grade 3 Concussion (historical, do not use for return to play)
    1. Approach
      1. See Closed Head Injury
      2. Urgent Neurologic Exam at hospital ER
      3. Consider Head CT
    2. First Grade 3 Concussion
      1. Return to play after asymptomatic for at least 1 month
    3. Second Grade 3 Concussion
      1. Termination from Collision Sports for the season
    4. Third Grade 3 Concussion
      1. Termination of sport
  6. References
    1. Whiteside (2006) Am Fam Physician 74(8):1357-62 [PubMed]

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