Treatment of Concussion in High School Athletes: A Proposed Protocol for Athletic and Academic Return to Activity

OBJECTIVES: Growing evidence suggests that there may be significant long term sequellae of cumulative concussions, which may include prolonged cognitive deficits and physical symptoms. There are a growing number of concussions each year in high school athletes that occur during sports. The objective of this study is to investigate the impact of cerebral concussions on athletes to gain a deeper understanding of sports related cerebral concussions that will ultimately lead to development of better management and prevention strategies. The hypothesis of the current study is that adolescent athletes who suffer from sports-related concussions demonstrate neurocognitive and neuropsychological deficits that affect both athletic and academic performance. To date, no current guidelines exist for return to academic activities, such as classroom attendance and schoolwork. METHODS: A review of prospectively collected data of all student athletes who suffered a concussion during athletics in a single high school from 2006 to 2010. The following validated patient-reported outcome scores were used to assess function and symptom scores pre- and post-injury: Impact Score, and SAC score. Concussed athletes completed baseline and post injury Immediate Post-concussion Assessment and Cognitive Test (ImPACT), and SAC testing on the same day. Athletes then followed the Zurich consensus guidelines for RTP. Documented concussions were categorized by time missed from participation using severity outcome intervals (same-day return, 1- to 2-day return, 3- to 6-day return, 7- to 9-day return, 10- to 21-day return, >21-day return, no return). All clinical notes from a single athletic trainer were reviewed for each athlete. The clinical data collected included patient demographics, history of concussions/migraine headaches/ depression/ anxiety, current concussion components, sideline (SAC) and computer-based (ImPact) neurocognitive testing, physical exertion post-concussion, and the total number of days to return to play. RESULTS: There were 120 concussions that occurred during athletics in a single high school between 2006 and 2011. There were 104 athletes (107 concussions) included in our study (64 males, 40 females). The average age at time of injury was 16 ± 1.24 years (Range 14-20). There were 62 injuries with an on Field SAC exam (Average 25 ± 3), 81 patients had a SAC exam 1 day after injury, 43 patients had both on field and post day 1 injury SAC exams (Mean Difference in scores 3±4). The average time until asymptomatic was 20 (Range 4-147) days, and average time for RTP was 39 (Range 6-147) days. In this cohort of high school athletes, RTP within the first week after concussion was unlikely. There were 7 athletes who had documented academic accommodations. CONCLUSION: Athletes that suffered a concussion during athletic play were unlikely to return to sports in less than a week. We found the Zurich consensus exertion protocol was important to differentiate athletes that were asymptomatic at rest, but had return of symptoms with exertional stress. Based on these results athletes were able to safely return to play without re-injury once the SAC and ImPACT test returned to baseline. In addition, athletes subjectively had an improvement in symptoms when academic accommodations were instituted as well.