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Concussion Consensus Statement Encourages Gradual Return to School

Student-athletes should take a gradual approach to returning to school and social activities after sustaining a concussion, according to the latest consensus statement on concussion in sport released Tuesday.

The statement is the product of the Fourth International Conference on Concussion in Sport held last fall in Zurich. Roughly 30 of the world's leading sports-concussion experts collaborated on the document, which covers everything from the definition and symptoms of a concussion to best practices for concussion prevention and recovery.

While it's possible to bounce back from a majority of concussions within a relatively short time span (7-10 days), children and adolescents could face a longer recovery period, based on previous research. As a student-athlete recovers from a concussion, "school attendance and activities may also need to be modified to avoid provocation of symptoms," the consensus statement suggests.

The panel of experts who authored the document agreed that no child or adolescent should return to physical activity or playing their sport until he or she has successfully returned to school.

This particular suggestion meshes well with the recommendation from the American Medical Society of Sports Medicine, which recently released its own position statement on concussion in sport. The society notes that when recovering from a concussion, "students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from concussion."

The panel from the Zurich conference says that physical and cognitive rest is "the cornerstone of concussion management" until the acute symptoms resolve. The panel also noted that further research is necessary before determining the ideal amount of rest and type of rest needed.

"As all brain injuries are different, doctors should be sure to treat on a case-by-case basis rather than imposing an arbitrary time frame," Christine Baugh, the research coordinator at the Boston University Center for the Study of Traumatic Encephalopathy, told me in a 2011 interview.

Return-to-Play Policies

The panel urges extra caution when allowing student-athletes to return to physical activity and sports after a concussion, due to both the prolonged recovery time and physiological differences between children and adults.

Compared to adults, children are effectively "bobble-heads" with a weak head-to-body ratio, as noted last month by concussion expert Chris Nowinski at the fourth Youth Sports Safety Summit.

The consensus statement lays out a five-step graduated return-to-play process, just as the 2008 consensus statement did, in which athletes would have to remain symptom-free for 24 hours to advance to the next step. Student-athletes should start with light aerobic exercise, such as walking or stationary cycling, before progressing to sport-specific exercise, non-contact training drills, full-contact practice, and finally, a return to normal game play.

In this particular case, it's better to be safe than sorry, the panel suggests.

"It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents," the consensus statement says.

The panel also addresses the role of neuropsychological testing in regards to concussion management in the consensus statement, but stops short of recommending its widespread routine use due to insufficient evidence.

The statement says neuropsychological testing "contributes significant information in concussion evaluation," but should never be used in isolation when making a return-to-play decision. Instead, neuropsychological tests should be one component of a multi-faceted approach to determining when a student-athlete is ready to return after sustaining a concussion.

Next Steps

The panel found "no good clinical evidence" that the protective equipment available today (such as helmets, mouthguards, etc.) will prevent concussions, despite claims by some manufacturers that would suggest otherwise.

In fact, protective equipment sometimes leads to players engaging in more dangerous behavior, "which can result in a paradoxical increase in injury rates," the consensus statement says.

Instead of focusing on equipment-based solutions for the time being, the panel recommends looking at particular rule changes that can reduce the incidence or severity of concussions.

For youths, evidence presented at the Zurich conference last fall suggested that the elimination of body checking from Pee Wee ice hockey helped prevent injuries. USA Hockey banned full-body checking in leagues for children 12 and younger in 2011.

The panel also notes that referees play an essential role, as "rule enforcement may be a critical aspect of modifying injury risk in these settings."

The concussion consensus statement was co-published online Tuesday in the British Journal of Sports Medicine and the Clinical Journal of Sports Medicine.

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