Clinical Consult: Back to school and play after a concussion

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Approximately 300,000 high school athletes are diagnosed with concussion annually, and managing their return to school and sports can present a challenge for the primary care provider. Some physicians recommend cognitive rest, while others don’t, and data supporting either approach have been scant.

The American Academy of Pediatrics (AAP) released a clinical report titled “Return to Learning Following a Concussion” at its annual meeting in October 2013. Designed to provide guidance to physicians caring for adolescents after concussion, the report emphasizes relative cognitive rest — minimizing digital exposure and temporarily making adjustments in studying intensity — and a gradual return to full participation in the classroom.

Full cognitive and physical rest

A prospective cohort study, conducted at Boston Children’s Hospital and published in Pediatrics, provided critical data to support recommendations for temporarily reducing cognitive activity. Researchers reported athletes with concussions who limit high-intensity cognitive demand (which can include texting, reading and playing video games) may recover faster than those who don’t. Interestingly, it also showed that minimal cognitive activity for too long could be associated with prolonged recovery, perhaps due to cognitive deconditioning and the stress of interrupting normal daily routines.

Boston Children’s Sports Concussion Clinic typically prescribes full physical and cognitive rest for a minimum of three to five days. This means eliminating all sports and exercise, and could include staying home from school for a few days if symptoms are significant. As school is reintroduced and tolerated, then digital restrictions can be lifted and low intensity, non-contact exercise started.

Return to school

Further reading

Read the consensus statement released after the 4th International Conference on Concussion in Sport, as well as detailed concussion diagnosis and management advice on UpToDate.

Schoolwork is sometimes the hardest part to manage, but is an important elements of a student-athlete’s life. Students may still have some mild symptoms as they re-enter the school environment, but the care team’s goals should be to avoid exacerbating symptoms while preventing social isolation, physical and cognitive deconditioning, or getting too far behind in school.

Boston Children’s physicians recommend a gradual re-entry into school. A detailed note to teachers that suggests they offer students a longer time for tests and projects and defer high-stakes testing can facilitate the transition and minimize stress for student-athletes.

Return to practice and play

Athletes can start stretching and walking for exercise after the initial three-to-five-day rest period. More intense exercise and sports participation should be restricted until the athlete can fully tolerate school and symptoms (nausea, dizziness, poor concentration, amnesia) have resolved.

Boston Children’s Sports Concussion Clinic recommends athletes meet four criteria between returning to practice or games with potential contact:

  1. full resolution of all symptoms (no headaches, dizziness, amnesia, difficulty concentrating, or double or blurry vision)
  2. academic tolerance (ability to attend school for a full day and complete schoolwork)
  3. exercise tolerance (with no lingering symptoms)
  4. cognitive testing assessment (sometimes as verbal testing or computerized testing in the office) as part of the overall assessment for safe return to play

We also suggest that athletes complete a minimum of two successful practices before returning to play.

These recommendations should be tailored to the individual patient, her symptoms and clinical history. Research suggests that there is a window of vulnerability after a concussion, and that this may continue even after symptoms resolve. A concussed athlete may be up to three times more likely to suffer a second concussion than an athlete who has never had a concussion.

A buffer zone between symptom resolution and return to play has value. The longer the symptom duration, the longer the period of symptom-free rest before return to play for contact sports. Some clinicians recommend an equal number of symptom-free weeks as symptomatic weeks.

When to refer to a specialist

Consider referral to a specialist if there are unusual or prolonged symptoms (beyond two to three weeks), or if there is reason to believe the athlete should never return to contact sports (multiple concussions with progressively lower threshold for injury, progressively longer recovery with successive injuries or incomplete recovery). Immediate referral to the Emergency Department should be considered if there is suspicion for associated cervical spine injury, witnessed loss of consciousness or seizure activity, progressively worsening symptoms over time or focal neurologic deficit.

Michael O'Brien concussion Sports Concussion Clinic Sports Medicine Division Orthopedic CenterMichael O’Brien, MD, is the director of the Sports Concussion Clinic at Boston Children’s Hospital, and an associate professor of orthopedics at Harvard Medical School.





Have questions about concussion management? Contact the Boston Children’s Hospital Sports Concussion Clinic.