New Guidelines for the Management of Concussions
Graduated Return to Play Criteria for Athletes with Concussions
Jun 19, 2009
Historically, athletes with mild concussions were allowed to return to practice/competition as long as they reported that their symptoms (headache, dizziness, nausea, confusion) had dissipated. The new guidelines were developed to protect the athlete from possible further injury to his/her brain.
Information presented in the Consensus Statement on Concussion in Sport at the 3rd International Conference on Concussion in Sport held in Zurich (November, 2008) contradicts and supersedes previous concussion management protocol.
International Conference on Concussion
Researchers from the fields of clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training, and sports science were invited to participate in a panel discussion utilizing the organizational guidelines set forth by the Unites States National Institutes of Health for a formal consensus meeting (Journal of Science and Medicine in Sport, May, 2009).
These researchers presented data in a public session followed by questions and discussion. The expert panel then met and prepared the published consensus statement on concussion in sport. The statement included a number of content areas related to concussion in sport including the new guidelines for concussion management.
Both Physical and Cognitive Rest Required
Once a concussion is diagnosed, the focus needs to be on “physical and cognitive rest until symptoms resolve”. Physical rest has been a known treatment for concussion, but the statement added cognitive rest as a new criteria.
In other words, athletes who are recovering from a concussion need to quiet their bodies and their minds for efficient healing to take place. The quieter the athlete’s body and mind, the quicker the recovery. This may mean that athletes in school be required to miss classes as well as practice as part of their recovery plan.
Activities that “require concentration and attention (i.e., school work, videogames, text messaging) may exacerbate the symptoms and possibly delay recovery." (McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J, May, 2009)
Graduated Return to Play Progression
Most athletes recover within several days. To ensure a gradual and safe progression for athletes to return to play, the panel recommended a specific progression of activities. The progression levels begin with complete rest and progress through to return to play.
Each level should take 24 hours with the athlete asymptomatic (symptom free) before moving to the next level in the progression. If any symptoms occur during the progression, the athlete should drop back to the previous level and try to complete that level after a 24 hour rest period. The progression levels are listed below:
- No activity with complete physical and cognitive rest
- Light aerobic exercise (less than 70% of maximum heart rate)
- Sport specific exercise (drills specific to athlete’s sport)
- Non-contact training drills (more intense sport drills with no contact from other players)
- Full contact practice (following medical clearance)
- Return to play (normal game play)
Ideally, the progression should take about one week from asymptomatic rest to full competition. The challenge is going to be in implementing this program in the world of competitive athletics.
Convincing coaches and athletic administrators that this type of progression is necessary for the protection and health of the athlete is going to be a difficult task. Historically, coaches are used to having athletes with concussions return to play within 24 hours (if that long) of being asymptomatic.
Holding every athlete who shows signs and symptoms of concussion out of play for one week is going to cause tension among the athlete, the medical staff, and the athletic staff. The new progression is a step in the right direction for protecting athletes. The challenge is going to be getting buy-in from the athletes, their parents, their coaches, and their athletic staff.
