Concussions are commonly encountered in the Emergency Department. We have previously discussed an approach to the question of when a patient “can return to sport.” That recommendation has been revised (calling for us to Rebake this Morsel) and now also pays specific attention to the important aspect of scholastic activities. Let’s take a quick minute to digest a morsel on the current concussion in sport recommendations with respect to Return to Learn and Return to Sport:
Return to Learn and Return to Sport: Concussion Basics
- Concussion is a mild traumatic brain injury caused by a direct force to the hear, neck, or body that leads to force being transmitted to the brain.
- It does NOT have structural brain damage visible on standard neuroimaging.
- In the research setting, abnormalities can be found via functional, blood flow, or metabolic imaging.
- Mild traumatic brain injury also includes a larger group of injuries that may have evidence of structural injury.
- Concussion – Presentation [Silverberg, 2023]
- There is no definitive test to diagnose concussion in the ED.
- Diagnosis requires a history of blunt trauma followed clinical signs and/or symptoms:
- Clinical Signs:
- GCS of 13-15 (on presentation to the ED, or within 30 minutes of the injury)
- AND at least ONE of the following:
- Loss of consciousness
- Amnesia
- Alteration in mental status:
- Reduced/Inappropriate responsiveness or
- Slowness to respond to questions/instructions or
- Agitation or
- Inability to follow two-part commands or
- Disorientation
- Any neurological deficit (ex, weakness, visual changes, seizures, incoordination)
- Clinical Symptoms (having 2 or more of the following):
- Subjective confusion/ disorientation
- Headache, nausea, dizziness, balance problems, vision problems, sensitivity to light, and/or sensitivity to noise.
- “Brain Fog” = feeling slowed down, difficulty concentrating
- Emotional lability, irritability
- Clinical Signs:
Return to Learn and Return to Sport
- Defintions: [Patricios, 2023]
- Return to Learn = Return to pre-injury learning activities with no new academic support, including school accommodations or learning adjustments
- Return to Sport = completion of the return to sport strategy with no symptoms and no clinical findings associated with the current concussion at rest and with maximal physical exertion.
- Progression through Return to Learn and Return to Sport:[Patricios, 2023]
- Is individualized and based on the person’s symptoms
- Typically takes a minimum of 1 week.
- May take up to 1 month
- Should be monitored by health care provider
- Significant change from before
- No longer recommend “Complete Rest” as the initial stage.
- Relative rest is now preferred for the first 24-48 hrs.
- Now highlights the scholastic component!
Return to Learn Strategy [Patricios, 2023]
| Step 1: Relative Rest (24-48hrs) | Minimize reading and screen use. Driving restrictions. Gradual return to ADLs. |
| Step 2: Resume School/Cognitive Activities | Homework, Reading. Increase tolerance of workload. |
| Step 3: Part-time School / Work | Introduce schoolwork / employment. May need increased breaks. Build more tolerance for typical mental efforts. |
| Step 4: Full-time School / Work | Continue to progress in activities until tolerant of full day of work with only mild symptoms. Return to cognitive baseline. |
Return to Sport Strategy [Patricios, 2023]
| Step 1: Relative Rest (24-48 hrs) | Resume ADLs. Gradually reintroduce school/work tasks. |
| Step 2a: Light Aerobic exercise Step 2b: Moderate Aerobic exercise | Walking, stationary bike, light resistance training. Increase heart rate. |
| Step 3: Individual Sport Exercise | Running, training drills, but avoiding any head impact. Increase movement and change of direction. |
| Step 4: Non-Contact Training | Throwing, working in team environment. Resume usual intensity of exercise and cognitive associated tasks. |
| Step 5: Full Contact Practice | Normal training. Coaching staff to fully assess skills. |
| Step 6: Return to Sport | Normal game play. |
Moral of the Morsel
- It’s All Relative! Do not recommend complete isolation and being in a cocoon after a concussion. Relative rest is best for the first 1-2 days!
- It’s Not All About the Sport! Sure, I love sports as much as anyone… but scholastic performance is paramount!
- It is Individualized! After being relatively rested… then progression through the Return to Learn and Return to Sport is tailored for the individual and needs to be monitored, but… at minimum it should take a week.
Reference:
Silverberg ND, Iverson GL; ACRM Brain Injury Special Interest Group Mild TBI Task Force members:; Cogan A, Dams-O-Connor K, Delmonico R, Graf MJP, Iaccarino MA, Kajankova M, Kamins J, McCulloch KL, McKinney G, Nagele D, Panenka WJ, Rabinowitz AR, Reed N, Wethe JV, Whitehair V; ACRM Mild TBI Diagnostic Criteria Expert Consensus Group:; Anderson V, Arciniegas DB, Bayley MT, Bazarian JJ, Bell KR, Broglio SP, Cifu D, Davis GA, Dvorak J, Echemendia RJ, Gioia GA, Giza CC, Hinds SR 2nd, Katz DI, Kurowski BG, Leddy JJ, Sage NL, Lumba-Brown A, Maas AI, Manley GT, McCrea M, Menon DK, Ponsford J, Putukian M, Suskauer SJ, van der Naalt J, Walker WC, Yeates KO, Zafonte R, Zasler ND, Zemek R. The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Arch Phys Med Rehabil. 2023 Aug;104(8):1343-1355. doi: 10.1016/j.apmr.2023.03.036. Epub 2023 May 19. PMID: 37211140.
Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, Davis GA, Echemendia RJ, Makdissi M, McNamee M, Broglio S, Emery CA, Feddermann-Demont N, Fuller GW, Giza CC, Guskiewicz KM, Hainline B, Iverson GL, Kutcher JS, Leddy JJ, Maddocks D, Manley G, McCrea M, Purcell LK, Putukian M, Sato H, Tuominen MP, Turner M, Yeates KO, Herring SA, Meeuwisse W. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med. 2023 Jun;57(11):695-711. doi: 10.1136/bjsports-2023-106898. PMID: 37316210.
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