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Concussion Return to Play Guidelines: Longer Recovery Time Needed, Says Doctor

Departure from current guidelines recommended

If it was up to Dr. Lester Mayers, young athletes who suffer sports concussions would be not be allowed to return to play (RTP) for 4 to 6 weeks after injury, a significant departure from current guidelines which allow RTP 1 to 2 weeks after an athlete's concussion signs and symptoms clear, both at rest and during exercise.

Writing in the September 2008 issue of the Archives of Neurology, Dr. Mayers, a sports medicine physician at Pace University in Pleasantville, New York, recognized that adopting longer recovery period would "probably provoke concern and resistance at all levels of sport."  But, he said, keeping athletes out of sports for a longer period was supported by recent studies that showed that significant degrees of functional abnormality persisted in athletes for at least a month after injury and that cast doubt on whether complete recovery was truly possible in the 1 to 2 weeks after concussion.

"If one accepts [the] definition of concussion [as] a trauma-induced alteration of mental status," writes Dr. Mayers,  "safe RTP might require at least 4 to 6 weeks to facilitate more complete recovery and to protect from reinjury" (which one earlier study found occurred much more frequently in the immediate period after a concussion).

As Dr. Mayers notes, physicians and athletic trainers do not currently have reliable and specific measures of brain damage and/or dysfunction to determine the appropriate time for athletes to return to play (RTP).  As a result, the RTP decision is an estimate based on the clearing of symptoms, a return to pre-concussion levels of cognitive functioning on neuropsychological tests, and completion by the athlete of a stepwise progression of aerobic and sport-specific exercises without the return of concussion symptoms.  Recognizing that the science of concussion is still in its early stages, the 2009 Prague Consensus Statement1 acknowledges that the "the science of concussion is evolving and that management and return to play decisions remain largely in the realm of clinical judgment on an individualized basis."

RTP recommendations, Dr. Mayers notes, are complicated by several factors:

  • Some athletes will minimize and/or deny symptoms so they can return to the field more quickly;

  • Neuropsychological test results may lack a pre-concussion baseline for comparison, may vary in reliability after repeated testing and because of a practice effect; and

  • Some athletes diagnosed as having their first concussion report that they may have suffered concussions in the past that went undiagnosed.

"Given the prevalence of sports head injury [an estimated 3.5 million sports concussions per year in the U.S.] and the number of young brains at risk, a post-concussion RTP interval of at least 4 weeks is imperative," argues Dr. Mayers.

1. Consensus Statement on Concussion in Sport: the 3rd InternationalConference on Concussion in Sport held in Zurich, November 2008.  Br.J. Sports Med. 20090: 43:i76-i84.