PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION

Keith H May; David L Marshall; Thomas G Burns; David M Popoli; John A Polikandriotis

. 2014 Apr;9(2):242–255.

PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION

Keith H May ^1,^✉, David L Marshall ¹, Thomas G Burns ¹, David M Popoli ¹, John A Polikandriotis ¹

PMCID: PMC4004129 PMID: 24790785

Abstract

Purpose/Background:

In 2010, the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. The guidelines include a six‐step process that provides structure to guide an athlete who is recovering from a concussion in a gradual return to play (RTP) by allowing participation in increasingly difficult physical activities. Unfortunately, the guidelines fail to take into account the variability that occurs within different sports and the resulting challenges medical professionals face in making sure each athlete is able to withstand the rigors of their specific sport, without return of symptoms. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines.

Description of Topic:

The intention of the sport specific guidelines is to maintain the integrity of the current six‐step model, add a moderate activity phase highlighted by resistance training, and to provide contact and limited contact drills specific to the athlete's sport and/or position. The drills and activities in the proposed seven‐step programs are designed to simulate sport specific movements; the sports include: football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey. These activities will provide sports specific challenges to each athlete while simultaneously accomplishing the objectives of each stage of the RTP progression. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions.

Discussion/Relation to Clinical Practice:

There have been significant strides in the management and care of concussed athletes. However, there continues to be a lot of confusion among, athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed several sports‐specific RTP guidelines.

Level of Evidence:

Keywords: Concussion, pediatric, return to play guidelines, sports

BACKGROUND/PURPOSE

Attention to sports related head injuries, specifically concussions, has increased over the last ten years.¹ The increased interest is likely multi‐factorial, occurring due to the impact of concussions on high profile professional athletes coverage in the popular media, and the large number of teens participating in contact and collision sports. More than half of all high school students, over 7.7 million boys and girls, participated in sports during the 2012‐2013 school year compared to 6.8 million during the 2002‐2003 school year.²

Consequently, the overall number of reported head injuries continues to rise. In fact, Langlois et al reported that at least 1.6‐3.8 million sports related concussions occur each year in the United States.³ While the majority of concussion symptoms resolve within 10 days to two weeks,⁴ the consequences of returning an athlete to play too soon following a concussion are now beginning to be understood. For example, there is a significant risk for a second concussion whose compounding effects can be detrimental to the adolescent athlete.^5‐13

In 2001, a multidisciplinary group of sport and medical professionals met in Vienna, Austria at the International Conference on Concussion in Sport (ICCS) and has since met three additional times with the specific objective of improving the evaluation, management, and return to play of concussed athletes.^14‐17 Interestingly, the pediatric and adolescent athlete was not considered until the 2008 conference that occurred in Zurich, Switzerland where three significant questions were raised: 1) Which symptom reporting scale is the most appropriate for this age group?; 2) Which tests are useful and how often should baseline testing be performed?; and 3) What are the most appropriate return to play criteria for the elite and non‐elite child and adolescent athlete? In 2012 and in response to the 2008 conference, the ICCS developed the child SCAT 3 (for ages 5‐12) for sideline use, recommended that neurophysiological testing be used broadly the same as adults with consideration made toward age appropriate cognitive development, recommended that children make a complete return to school prior to a return to play, and recommended a more conservative return to play progression, secondary to a child's physiological response to a head injury and their tendency to take longer to recover.¹⁷

In 2010, the American Academy of Pediatrics (AAP) published basic concussion management guidelines for children and adolescents, adapted from the ICCS recommendations that emphasized a graduated return to play (RTP) protocol and the importance of having an athlete follow a stepwise progression in their RTP.¹⁸ Table 1, adapted from the AAP guidelines, shows the recommended RTP progression.

Table 1.

Graduated Return‐to‐Play Protocol, with additional Step 6¹⁸

Graduated Return‐to Play Protocol
Step	Rehabilitation Stage	Objective of Stage
1	No activity	Recovery
2	Light aerobic exercise	Increased heart rate
3	Sport‐specific exercise	Add movement
4	Non‐contact training drills	Exercise, coordination, cognitive load
5	Full‐contact practice	Restore athletes confidence, coaching staff assess functional skills
6	Return to play

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According to the recommended protocol, a concussed athlete begins the 6‐step protocol and moves through the progression at 24‐hour intervals as long as no symptoms occur. If an athlete develops symptoms the progression should be stopped and the athlete must be returned to the previous phase. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions.

It is important to recognize that the mechanisms of concussive injury and force of collision vary among sports. In football, for example, helmet‐to‐helmet collisions are common, whereas contact from a stick, puck or ball can occur in ice hockey, lacrosse, or soccer. For this reason, every concussion is unique and athletic medical providers should consider sport specific RTP guidelines utilizing symptom reports, as well as cognitive and balance examination data to track recovery. Ultimately, this will assist in developing detailed understanding regarding how and when to return pediatric athletes back their sports activities. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines.

DESCRIPTION OF TOPIC

The following sports specific RTP criteria developed by a multidisciplinary sports medicine team at Children's Healthcare of Atlanta was written and implemented into the Atlanta, GA metro service area in 2012 (Appendices 1‐10). The intention was to maintain the integrity of the current 6‐step basic progression suggested by the ICCS and adopted by the AAP, spanning the time period from no physical activity to full RTP. The authors propose adding a moderate activity step highlighted by resistance training and modifying steps three and four to include noncontact and limited contact drills specific to the athlete's sport.

Assessing an athlete's tolerance to resistance training is important because weight training can increase intracranial pressure and exacerbate post concussive symptoms.¹⁹ Resistance training should be introduced with low weight/high repetition exercises.²⁰ The specific sports chosen for this new 7‐step program were known to be of high risk for head injury and included football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball and ice hockey. Each sport was considered for drills and activities that could be completed by the athlete that would simulate sport specific movements while simultaneously accomplishing the objectives of each stage of the RTP progression. As with the basic guidelines, each step represents a 24‐hour period unless an athlete develops symptoms. A pediatric or adolescent athlete should begin the RTP progression once they have achieved a full return to school (cognitive activities). If symptoms occur, the progression should be stopped and the athlete returned to the previous phase where symptoms did not occur. A list of common concussion symptoms described by the AAP is included in Table 2.

Table 2.

Signs and Symptoms of a Concussion¹⁸

Signs and Symptoms of a Concussion
Headache	Change in sleep patterns
Dizziness	Vision changes
Nausea/Vomiting	Difficulty concentrating
Sensitivity to light	Difficulty remembering
Loss of balance	Numbness or tingling anywhere in the body
Irritability	Feeling more emotional

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To reiterate, the final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions. This could include a physician, nurse practitioner, physician assistant, certified athletic trainer, or board certified sports physical therapist.

DISCUSSION

The pathophysiology, recognition and treatment of concussions are becoming far better understood than in years past. Most concussion management programs now stress cognitive rest, physical rest, the use of neurocognitive testing, and utilization of return to play guidelines. Despite these improvements in the care of athletes, there continues to be a lot of confusion among athletes, parents, and coaches as to the proper management of a concussion, particularly those that occur in children. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed these sequential sports‐specific RTP guidelines. Further research is warranted in order to validate these guidelines and their potential impact on return to play adherence and overall success. Adherence to even the current general return to play recommendations continues to be a challenge in the pediatric and adolescent sporting community. In 2009, Yard and Comstock found that one in six athletes failed to follow a standardized RTP guideline and thus frequently returned to their sport prematurely.²¹ Furthermore, Hollis et al reported that in a group of 296 rugby athletes with suspected concussions only 66 returned to play with medical clearance.¹² Similarly, Sye et al reported 145 of 187 rugby players were only compliant with the initial rest period.²³

Of special concern is that there are currently no suggested RTP guidelines for athletes under the age of 13. The consensus guidelines are described to be applicable for adolescents 13 years of age and older. An age appropriate physical, cognitive testing and symptom checklist is recommended as a component of the assessment as patients below age 13 tend to report concussion symptoms different from adults.¹⁷ Consensus in the literature is that those who manage a younger athlete with a concussion should be prepared to extend the recovery timeline.^17,24 The extended time is a product of the different physiological response that children and adolescents demonstrate as a result of a concussion (e.g. diffuse cerebral swelling). The actual recovery time may vary based on the individual patient.^17,24 Additionally, RTP guidelines may need to be adjusted for those who have experienced a prior head injury. Multiple authors have described that those who have suffered a prior injury have up to a 5.8 fold increased rate of re‐injury.^6‐13 Therefore, treating an athlete with multiple concussions involves emphasizing the need to consider the long‐term consequences and recovery prior to RTP.^25‐27

Lastly, many states have passed legislation designed to address the growing concern of traumatic brain injuries and concussion among young athletes. In addition to the legislative efforts that may govern RTP guidelines, a team approach that involves health care providers, parents, athletes, and coaches is key for the long‐term health of the athlete.

Appendix 1

Return to Physical Activity Following Concussion‐Cheerleading

Stage	Activity	Cheerleading Specific Exercise	Objective of the Stage
1	No physical activity; Complete physical and cognitive rest	No activity	Recovery and elimination of symptoms
2	Light aerobic activity	10‐15 min of walking at home or at gym, or stationary bike	Add light aerobic activity and monitor for symptom return
3	Moderate aerobic activity Light resistance training	20‐30 min jogging Resistance training ‐body weight squats and push‐ups 1 set of 10 reps each	Increase aerobic activity and monitor for symptom return
4	Vertical work (No inversion)	Moderate conditioning jumps (toe‐touch, Herkie, double hook), 15 yard sprints (as in tumbling pass), stunting with feet on ground *No tumbling	Maximize aerobic activity Introduce head movements Monitor for symptoms
5	Intro level tumbling	Round‐off Walkovers Handspring (1) Light tumbling Progress from non‐inverted lifts to inverted lifts Cradle catch	Maximize aerobic activity Add deceleration/rotational forces in controlled setting Introduce inversion ‐ vestibular stress Monitor for symptoms
6	Full practice (after medical clearance)	Normal training activities	Reassess for symptoms every 30 minutes throughout the practice Monitor for symptoms
7	Unrestricted workouts	Return to competition	Assess frequently Monitor for symptoms

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Progress to the next stage may occur every 24 hours as long as symptoms do not return.
It is recommended that you seek further medial attention if you fail more than 3 attempts to pass a stage

Appendix 2

Return to Physical Activity Following Concussion‐Gymnastics

Stage	Activity	Gymnastic Specific Exercise	Objective of the Stage
1	No physical activity; Complete physical and cognitive rest	No activity	Recovery and elimination of symptoms
2	Light aerobic activity	10‐15 min of walking at home or at gym, or stationary bike	Add light aerobic activity and monitor for symptom return
3	Moderate aerobic activity Light resistance training	20‐30 min jogging Resistance training ‐body weight squats and pushups 1 set of 10 reps each	Increase aerobic activity and monitor for symptom return
4	Vertical work	Level 1‐2‐ handstands, choreography on low beam no jumps/turns, swings on bar, no vault Level 3‐4‐ vault run with peel off, glide swings on bars, cast to block on bar, tap swings Level 5‐6‐ cast above horizontal Level 7‐8‐ cast to HS return to block Level 9+‐ any skill listed above Note: it is acceptable of a higher level skilled athlete to perform a lower level skill	Maximize aerobic activity Introduce rotational head movements Monitor for symptoms
5	Intro level tumbling	Ll‐2‐ cartwheel, bridge kick‐overs, backward and forward rolls, jumps and leaps, turns and spins, competition vault, round‐off on tumble track L3‐4‐ walkovers, backward roll to HS, vault drills‐ no full vaults, round‐off, kips on bars, back and front hip circles, front and back HS on tumble track L5‐6‐ clear hips, stalder, sole circles, long hang pullover, tumbling on tumble track with saltos L7‐8‐ giants on bars, handsprings on vault, back handsprings on low beam L9+‐ straight tumbling on tumble track no twisting (may progress to full twist provided symptom free), no releases on bars. Handsprings on vault, Yurchenko timers (vaulting preferably into pit)	Maximize aerobic activity Add deceleration/rotational forces in controlled setting Monitor for symptoms
6	Full practice (after medical clearance)	Normal training activities	Reassess for symptoms every 30 minutes throughout the practice Monitor for symptoms
7	Unrestricted workouts	Return to competition	Assess frequently Monitor for symptoms

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Progress to the next stage may occur every 24 hours as long as symptoms do not return.
It is recommended that you seek further medial attention if you fail more than 3 attempts to pass a stage

Appendix 3

Return to Physical Activity Following Concussion Football

Stage	Activity	Football Specific Exercise	Objective of the Stage
1	No physical activity; Complete physical and cognitive rest	No activity	Recovery and elimination of symptoms
2	Light aerobic activity	10‐15 min of walking at home or at field, or stationary bike	Add light aerobic activity and monitor for symptom return
3	Moderate aerobic activity Light resistance training	20‐30 min jogging w/helmet Resistance training ‐body weight squats and push‐ups 1 set of 10 reps each	Increase aerobic activity and monitor for symptom return
4	Non‐contact football‐specific drills	Moving in/out 3 point stance, bear crawls through tunnel, tires, step over bags (vertical and lateral), QB/center exchange, QB drop backs, passing, break downs and plant, jump cuts, backpedaling, match the hips, up/downs *Start w/o helmet; progress to helmet and shoulder pads if symptom free	Maximize aerobic activity Accelerate to full speed with change of directions (cuts) Introduce rotational head movements Monitor for symptoms
5	Limited contact football drills	Stage 4 workout in full pads Hit/push pads then sled (focus on technique‐head up, square up, stay low), step and hit, run and hit, leverage drill, punch drill	Maximize aerobic activity Add deceleration/rotational forces in controlled setting Monitor for symptoms
6	Full contact practice (after medical clearance)	Normal training activities	Reassess for symptoms every 30 minutes throughout the practice Monitor for symptoms
7	Return to play	Normal game play	Assess frequently Monitor for symptoms Consider one side of the ball only, no special teams play

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• Progress to the next stage may occur every 24 hours as long as symptoms do not return.