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Concussion Identification, Evaluation and Management: A Step-By-Step Process

New guidelines for concussion mangement: from pre-season to on the field to sideline assessment, diagnosis, treatment and return to play

7. Return to school

  • Because of the dearth of research in this area, and the fact that each athlete's response to and recovery from concussion is different, there are no standardized guidelines for returning a concussed student-athlete to school, although the most recent Zurich consensus statement [1] and accompanying Child-SCAT3 [4] suggest that taking a couple of days off from school after a concussion may be beneficial.
  • If the athlete develops increased symptoms with cognitive stress, he or she may require academic accommodations, such as reduced workload, extended test-taking time, days off or a shortened school day. 
  • Expert advice varies on whether an athlete should be allowed to return to sports if they have not returned to their academic baseline after concussion. The Zurich consensus statement [1] and a majority of concussion experts, take the view that "no return to sport or activity should occur before the child/adolescent has managed to return to school successfully." The AMSSM position statement [2] is couched in more ambiguous language: "Consideration should be made to withhold an athlete from contact sports if they have not returned to their 'academic baseline' following their concussion." (emphasis supplied).

8. Return to play (RTP)

  • RTP after concussion should be individualized, gradual and progressive and should consider factors that may affect individual risk and outcome. [1,2]
  • The athlete should be free of concussion symptoms at rest as well as during and after exertion before returning to full participation.[1,2]
  • The athlete should also have a normal neurological exam, including a normal cognitive and balance evaluation, ideally compared to a preinjury baseline.
  • Once an athlete is symptomatic and has returned to their baseline measures (if available), a gradual and medically supervised incremental return to activity should be initiated and include a stepwise increase in physical demands, sports-specific activities and physical contact. [1,2] This progression may take days to weeks to months depending on the individual responses and modifying circumstances. For more on the recommended return-to-play protocol, click here.
  • The RTP progression should be individualized, with symptoms, cognitive, and balance exams used for tracking recovery.
  • A final RTP/practice determination should occur with documented medical clearance from a licensed healthcare provider trained in the evaluation and management of concussion (as is now required by law in all but a handful of states).

1. McCrory P, et al. Concussion statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.

2.Harmon K, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15-26.

3. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013 (published online ahead of print March 18, 2013): DOI:10.1212/WNL.ob013e31828d57dd (accessed March 23, 2013)

4. SCAT3, Br J Sports Med 2013;47:259

5. McCrea M, Iverson G, Echemendia R, et al. Day of injury assessment of sport-related concussion. Br J Sports Med 2013;47:272-284.

6. Cantu R, Hyman M. Concussions and Our Kids (Houghton Mifflin Harcourt 2012), pp. 60-61.

7. King D, Brughelli M, Hume P, Gissane C. Concussions in amateur rugby union identified with the use of a rapid visual screening tool. J Neuro Sci 2013, http://dx.doi.org/10.1016/j.jns.2013.01.012 (published online ahead of print)(accessed February 14, 2013)

8. King D, Clark T, Gissanec C. Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study. J Neuro Sci http://dx.doi.org/10.1016/j.jns.2012.05.049.

9. Galetta K, Brandes L, Maki K, Dziemiannowicz M, Laudano E., Allen M, Lawler K, Sennett B, Wiebe D, Devick S, Messner L, Galetta S, Balcer L. The King-Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort. J Neuro Sci 2011; 309(1):34-39.

10. Lau B, Collins M, Lovell M. Sensitivity and specificity of sub-acute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med 2011;39:1209-1216.

11. Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes.  Clin J Sport Med 1995;5(1):32-35.

12. Echemendia R, Bruce J, Bailey C, Sanders J, Arnett P, Vargas G. The Utility of Post-Concussion Neuropsychological Data in Identifying Cognitive Change Following Sports-Related MTBI in the Absence of Baseline Data.  Clin Neuropsy 2012;26(7):1077-1091.

13. Schmidt J, Register-Mihalik J, Mihalik J, Kerr Z, Guskiewicz K. Identifying Impairments after Concussion: Normative Data vesus Individualized Baselines. Med & Sci Sports & Exer. 2012;44(9):1621-1628.

14. McClure DJ, Zuckerman SL, Kutscher SJ, Gregory A, Solomon GS. "Baseline Neurocognitive Test Results in Non-concussed Athletes: Does Sleep Matter?"  Presentation paper, AOSSM (June 13, 2013)

15. Moser RS, Schatz P, Neidzwski K, Ott S.D.  Does Group vs. Individual Administration Affect Baseline Neurocognitive Test Performance? Am J Sports Med (in press)

16. Schatz P, Moser RS, Solomon GS, Ott SD,  Karpf R. Incidence of invalid computerized baseline neurocognitive test results in high school and college students. J. Ath Tr  2012;47(3):289-286.

17. Broglio SP, Ferrara MS, Macciochi SN, Baumgartner T A, Elliott R.  Test-retest reliability of computerized concussion assessment programs. J Ath Tr 2007;42(4):509-541.

18. Schatz P, Glatts C. "Sandbagging" Baseline Test Performance on ImPACT, Without Detection, Is More Difficult than It Appears. Arch Clin Neuropsychol (published online ahead of print February 11, 2013)

19. Howell D, Osternig L, Van Donkelaar P, Mayer U, Chou L. Effects of Concussion on Attention and Executive Function in Adolescents. Med Sci Sports Exer. 2013;45(6):1023-1029.

20. Kirkwood M, Randolph C, Yeates K. Sport-Related Concussion: A Call for Evidence and Perspective Amidst the Alarms. Clin J Sports Med. 2012;22(5):383-384.

21. Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47:304-307.

22. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics 2012;161(5):922-926.

23. Giza CC, Hovda DA, The Neurometabolic Cascade of Concussion. J. Ath Train 2001;36(3):228-235.

24. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am J Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011)

25. Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Forbes JA, Stills AK. Recovery from sport-related concussion: Days to return to neurological baseline in adolescents versus young adults.  Surg Neurol Int. 2012;3:130. Epub 2012 Oct 27.

26. Neary J., et. al. Cerebrovascular Reactivity Impairment after Sport-Induced Concussion, Medicine & Science in Sports & Exercise 2011;43(12): 2241-2248.

27. Maugans T, Farley C, Altaye M, Leach J, Cecil K. Pediatric Sports-Related Concussion Produces Cerebral Blood Flow Alterations. Pediatrics 2012;129:28-37.

28. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes.  Applied Neuropsychology: Child. 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012)

29. Resch J, et al. ImPact Test-Retest Reliability: Reliably Unreliable? J Athl Tr. 2013;48(3):000-000 doi: 10.4085/1062-6050-48.3.09 (ePub in advance of print).

30. Schatz P, et al. Long-term test-retest reliability of baseline cognitive assessments using imPACT. Am J Sports Med. 2009;10:38(1):47-53.

31. Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the concussion assessment battery. Neurosurgery. 2007;60(6):1050-

32. Erlanger D, Feldman D, Kutner K, et al. Development and validation of a web-based neuropsychological test protocol for sports-related return-to-play decision-making. Arch Clin Neuropsychol. 2003;18(3):293-316.

33. Elbin RJ, Schatz P, Covassin T. One-year test-retest reliability of the online version of ImPACT in high school athletes. Am J Sports Med. 2011;39(11):2319-2324.

Posted May 28, 2013; substantially revised August 10, 2013, April 2, 2015