Concussions: Treatment and return-to-play guidelines

Dr. O'Brien concussions athletes lead image
PHOTO ILLUSTRATION: PATRICK BIBBINS/BOSTON CHILDREN’S HOSPITAL

The end of summer and beginning of fall marks a time when physicians and athletic trainers begin to see a rise in concussions from athletes competing in both soccer and football. Though the football-concussion link is well-known, soccer also carries a significant risk for athletes.

In soccer, concussions are often the result of head-to-head contact or head-to-ground contact after an awkward fall. With players constantly leaping into the air to compete for lofted balls, it’s not surprising that these types of concussions regularly occur. Michael O’Brien, MD, director of the Sports Concussion Clinic at Boston Children’s Hospital, details the updated protocols for return to play after concussion and what physicians and trainers should be aware of during the soccer season.

Concussion treatment: First steps

“The biggest concern for concussions are the ones that go unreported or unrecognized,” says O’Brien. “There’s a window of vulnerability where sustaining more collisions can escalate symptoms, prolong recovery and even lead to long-term issues.” This is why O’Brien states that the first step in concussion treatment is to immediately remove the athlete from play. Whether or not the player is ultimately diagnosed with a concussion, removing them from situations where further collisions can occur is the first step in assuring their safety.

If it is determined that an athlete has sustained a concussion, it’s important to note that treatment protocol has changed in recent years. In the past, patients with concussion symptoms may have been prescribed prolonged rest in a dark room until symptoms subsided, but O’Brien explains why this is no longer the case, “It’s actually quite the opposite,” he says. “We’re trying to mitigate de-conditioning. Sitting in a dark room can promote irritability, trouble sleeping and other symptoms that we’re trying to prevent.”

Concussion return-to-play: Five stages

Stage 1

For the first two to four days after concussion, the athlete must be under “complete rest,” where they should refrain from as much physical and cognitive activity as possible, and may be kept out of school if their symptoms are significant.

Stage 2

The first stage should be followed by “reasonable rest,” where the athlete starts to be reintroduced to light or medium exercise and cognitive activity. These can be started once the athlete is able to tolerate being at school for full days and their symptoms are minimal. “We’re trying not to provoke symptoms with high-intensity exercise or high-intensity cognitive activity, but we are trying to reintroduce light-to medium-intensity exercise, which is always non-contact until they are completely recovered,” explains O’Brien.

This light- and medium-intensity activity begins with some stretching and walking, along with muscle activation. O’Brien refers to it as “pretty neutral with limited head movement.” These exercises include light aerobic conditioning and some resistance training.

Stage 3

When the athlete is symptom-free and tolerating school fully, they can move to stage 3 exercises. These are exercises such as running, jumping, plyometrics and challenging balance exercises. For soccer players, this stage is where they can begin working on change of direction and ball handling. However, maximal effort exercises should still be avoided, as well as any with a risk of contact. If it appears that symptoms start to worsen with increased cognitive or exercise load, both physical and cognitive work should be decreased until symptoms improve.

Stage 4

After several days of success with stage 3 exercises, the athlete can progress to stage 4. These exercises are practice- and game-intensity level activities, done at maximum intensity — although still avoiding any contact. The athlete should remain in this stage until the treating physician has given clearance for a full return to sport, and a neurocongnitive assessment — sometimes including a computerized test — is performed to ensure that the brain is fully recovered. Typically, it is suggested that the athlete completes at least two full intensity practices before they play in a game, in order to ensure that they are ready for the physical and cognitive challenges of playing at game speed.

Stage 5

Once the treating physician has cleared the athlete for a full return to their sport, they’ve entered stage 5 and have completed the return-to-play protocol. The athlete is now able to perform both physical and cognitive activities without restriction.

No easy task

While this system sounds straightforward on paper, treating a concussed athlete is far from simple. “The truth is, if an athlete has a return of symptoms, it’s going to be very difficult for a trainer to notice that when they’re busy watching all the other athletes as well,” says O’Brien. While neurocognitive tests can give an indication of an athlete’s cognitive status in a controlled setting, it’s much harder to make this determination while evaluating multiple players on the field. “A trainer or physician needs to be vigilant and recognize when a patient isn’t acting like themselves — whether their schoolwork is affected or they are playing out of sorts during practice.”

O’Brien further stresses that — because concussion symptoms may not be outwardly visible — the most important thing a trainer or team doctor can do is establish trust and communication with the athlete. If an athlete is willing to speak up when they feel that something is off, it can make the caregiver’s job that much easier. “And if a trainer or pediatrician wants assistance in assessing a patient, we’re always happy to help,” he says. “Treating an athlete who may have sustained a concussion is always a priority, so we make ourselves available for evaluation as soon as possible.”

Learn more about the Sports Concussion Clinic at Boston Children’s Hospital.

Attention PTs, ATs and physicians: register for the 2018 Micheli Lecture on the psychology of sports injury and rehabilitation. The lecture takes place Sunday, September 23rd at Boston Children’s Hospital. Continuing education credits are available.

Experts from orthopedics, sports medicine, sports psychiatry, pain medicine and clinical sports psychology will present interactive lectures and conduct multidisciplinary panels alongside athletes who have experienced significant sports injuries, and will discuss their rehabilitative process.