Return to Play After a Concussion

A concussion is a type of mild traumatic brain injury caused by a forceful blow or jolt to the head or body that disrupts how the brain normally works. A person does not need to be knocked out or lose consciousness to have a concussion.

Many parents wonder if it is safe for their young athlete to return to playing football, soccer, lacrosse or other sports after a concussion. An appropriately trained healthcare provider can answer these questions and provide guidance on when it is safe and sensible for an athlete to return to sports.

The importance of concussion recovery

Athletes should not be allowed to continue playing sports, including practices and conditioning, while recovering from a concussion for a variety of reasons:

• Recovery time: In one study among high school athletes, athletes who were immediately removed from play after a concussion recovered twice as fast as athletes who continued to participate.
• Worsening symptoms: Strenuous activity soon after a concussion has been associated with worsening symptoms.
• Increased risk: Parents and young athletes should be aware that a second head injury while an athlete is recovering from a concussion can increase the risk of complications, including the potential for worsening symptoms and longer recovery.

Catastrophic brain injuries, such as those that result in death or permanent neurologic injury, are extremely rare in youth sports. Nevertheless, it's important to understand that they can happen so that they can be identified immediately and appropriately managed.

What laws govern concussion return to play?

The youth sports concussion law (Senate Bill 40, or the "Jake Snakenberg Youth Concussion Act") took effect in 2012 and puts safety measures in place to help young athletes who suffer from a head injury while playing sports.

• Coaches need to complete a concussion recognition training annually. This includes all organized youth sports for kids 11 to 18 years old. This training may be completed through a free online course or through an in-person training by a healthcare professional with expertise in managing concussions.
• Coaches must immediately remove an athlete with a suspected concussion from play. If an athlete has been taken out of a game for a possible concussion, they should not be allowed to return to the game or practice the same day. The athlete will need to sit out of further practices/games until cleared by a healthcare professional.
• Coaches should always notify a parent of any athlete they remove from play due to a suspected concussion. Coaches should also give information to the parents regarding the signs and symptoms of concussion so they can monitor their child at home.
• A healthcare provider must evaluate a player with a suspected concussion and give written clearance for return to play, including practices and games.

How do multiple concussions affect return to play?

Concussion symptoms typically resolve within a few days to a few weeks, and generally there are no long-term problems. Most young athletes can return to sports once a medical provider has cleared them. There is no definite number of concussions that requires retirement or disqualification from sports, as each case should be considered individually. When an athlete has sustained multiple concussions, many factors are considered in the decision to return an athlete to competitive sports, including:

• Number of concussions
• Timing of concussions (interval between injuries)
• Duration of recovery and required treatment
• Presence of complications or incomplete recovery
• Injury threshold (level of force required to cause injury)
• Injury risk of desired activity
• Athlete and family priorities including the benefits of sports participation

We recommend consulting with a concussion specialist to help weigh the factors above so the parent and athlete can make the best decision for their situation.

What is second impact syndrome?

The idea that two closely spaced concussions results in a devastating brain injury has become known as "second impact syndrome." However, this phenomenon has come into question because research has not found that back-to-back concussions cause severe brain injury.

It is important to note that catastrophic outcomes can happen after sport-related head injuries. Fortunately, these outcomes in sports are extremely rare, occurring much less frequently than from activities we let our children do every day, such as riding in motor vehicles or biking. It's also important to remember that there are many scientifically known benefits to participation in sports including benefits for physical health, academic achievement, and social and emotional functioning.

Determining whether an athlete is ready to return to play

There is no single test that can definitively determine whether an athlete has had a concussion and when they are ready to return to play. Your healthcare provider should determine if the athlete is functioning at their typical level in all areas of life prior to clearance for sports. It can also be helpful to receive information from the athlete, their parents and teachers, as well as peers and coaches if possible.

Our providers typically consider clearance once the athlete is:

• Free of concussion symptoms for at least 24 hours
• Off any medications started for concussion symptoms
• Attending full days of school and tolerating a full academic workload (if applicable, depending on the time of year)

What are baseline cognitive tests?

Certain athletic programs require athletes to take a computerized baseline test before competing on a sport's team. These tests evaluate the athlete's cognitive functions to establish a baseline in the event of a concussion during the season. If an athlete is suspected of having a concussion during the season, a second test can be administered and compared to the baseline test. Unfortunately, these tests may not be as reliable or useful as originally thought, and should not be used in isolation to diagnose or manage a concussion.

Theoretically, these tests are appealing because they have the potential to provide additional information about an athlete's thinking, memory and response speed after a concussion. However, at present, the value of baseline testing remains scientifically questionable, especially for younger athletes.

Returning to school after a concussion

Athletes who have had a concussion should undergo a thorough medical examination soon after injury. After an injury, a brief period of reduced activity and rest may be beneficial (ex. a day or two), but most children won't need to miss many days of school. For students who could benefit from a gradual transition, returning for partial school days may be worthwhile before advancing to full days.

Learn more about returning to school after a concussion and how to create a concussion comeback plan for students.

Leading the way in concussion care

Children's Colorado's Concussion Program is committed to evidence-based, interdisciplinary care tailored to the individual patient, as well as to partnering with referring providers, school personnel and athletic clubs. Our team of board-certified pediatric experts in emergency medicine, sports medicine, rehabilitation, neuropsychology and neurosurgery are joined by certified athletic trainers, psychologists, physical therapists, nurses and other support. The entire team has special training in concussion to offer a streamlined, comprehensive approach to concussion.

To schedule an appointment or get more information about our Concussion Program, please call 720-777-2806. We are happy to consult with parents or referring providers before a patient is seen at Children's Colorado.