When should my child return to sports or school after a concussion?

Is it still rest and reset?

Why is this such an important topic, especially for parents? Well, approximately 2 million children under 18 will sustain at least 1 concussion. The most common cause of concussions for children are sports, then falls, then MVA (car, bike, scooter, ATV) but MVAs tend to result in most severe concussions. The medical definition of a concussion (also referred to as a mild TBI), is a head injury resulting in a Glasgow Coma Scale of 13-15 (measures severity, 13-15 is least severe), normal CT scan, no LOC or LOC under 30 minutes. Skills most often compromised include: emotional regulation, processing speed, working memory, sustained attention, and motor skills. Academic impairments typically secondary to those impairments. Concussions can also exacerbate preexisting ADHD, learning, language, motor and emotional diagnoses, but generally the child return to baseline, where the skills were prior. Historically, the “acute phase” of concussion was 10 days, but now it is thought to be shorter. Most concussions resolve within days but about 10-30% of those who experience a concussion will experience post-concussion syndrome, which means continued symptoms typically past the 4-week mark following initial concussion. Symptoms of PCS can include: fatigue, irritability, headache, dizziness, insomnia, poor concentration, forgetfulness and sensitivity to light and noise. PCS affects academic, vocational, social, and emotional functioning as well as overall quality of life.

So what do we know about the likelihood of a particular child developing post-concussion syndrome? In general, we know that a child’s recovery journey depends on the age, length of LOC, and location of injury and that MVAs produce the highest risk of PCS. For example, younger children generally experience less concussions, but when they do, the concussions can be quite severe. Because the brain is not fully matured in childhood, there tends to be worse outcomes in younger children in terms of long-lasting cognitive effects, while older children tend to have more emotional/pain symptoms but less long-term cognitive effects. Additionally, level of resilience, motivation to improve, mental health, family dynamics, and prior physical/cognitive functioning affect vulnerability of PCS. There is also an increased risk of PCS if there was pre-existing anxiety/depression/PTSD and/or vestibular or cervical dysfunction. Moreover, history of ADHD, language disorder, and learning differences, increase risk of PCS. Studies have also shown that girls may be more susceptible to somatic and emotional symptoms post-concussion. For some children, outcomes may be affected by how the child copes with bodily sensations related to fear, avoidance, and ambivalence (again vulnerabilities from prior anxiety, depression, trauma history etc). Also, up to 50% of children who suffer a concussion do not receive appropriate care because of unequal access and mismatched care, so this alone can be a significant factor in terms of likelihood of enduring symptoms if not treated in a timely and appropriate manner.

Aside from standalone concussions, it is also possible that there are cumulative effects of repeated head impacts (which are not necessarily to the level of concussions but still impactful), which are most common in soccer and football, that may lead to PCS. In fact, the REIMPACT study is presenting looking at brain alterations, vestibular processing, and other possible biomarkers indicative of cognitive effects of repeated impacts, including whether it increases vulnerability for neurologically based disorders later in life. For example, studies have shown that children ages 9-13 have more impaired cognition if they have had repeated exposure to head impacts, especially if overweight or in poorer health. Another research study, CARE4Kids, is using bloodwork, neuroimaging, autonomic data, and neuropsych results to analyze those that may be at increased risk for PCS. Additionally, research is being conducted in an effort to differentiate via imaging between complicated and non-complicated concussions, as there is a significantly higher rate of PCS in complicated concussions, so we can better create an appropriate treatment plan and return to activity.

Moreover, there is new framework (2025) being proposed by the National Institute of Neurological Disorders and Stroke, or NINDS, for labeling and classifying traumatic brain injury, including concussion, especially within the first 24 hours post-injury. There has been some pushback to the traditional “mild, moderate, severe” classification system in terms of giving false hope and/or inaccurate predictions of long-term recovery and progression. The new system referred to as “CBI-M” takes into account clinical tests (GCS and others), biomarkers (blood tests for proteins that are commonly elevated upon brain injury), brain scans (e.g., MRI, CT Scan), and medical history unique to the patient (e.g., prior mental health or learning disorders, gender, age etc.) to inform treatment and recovery. Additionally, newer medical terminology will be used such as “trauma axonal injury” and “microvascular injury.” Additionally, because of newer technology, both blood tests and brain scans are able to pick up on more details information that can be used to inform severity and intervention. This is system has been studied over the past 4 years, with data published in 7 separate studies across two peer-reviewed medical journals.

But if your child seems relatively okay after a concussion, how do you know when they are ready to return to sports or school, so they don’t end up with long-term symptoms? In the past there was more of a “wait and see” approach, but this has now has evolved to more proactive/early intervention approach, which has been shown to reduce stress and anxiety amongst children and parents. In the past, a 3 week break was recommended after a concussion, but now we know from this research this can make things worse instead of better. In fact, we have learned that prolonged rest can be very dangerous for long-term outcomes. While acutely (meaning the first 24-48 hours) rest is warranted to reset neurometabolic functions and energy levels, return to play should begin gradually between 24 and 48 hours after concussion, depending on severity of concussion. Children need the right balance or rest and return to play (RTP): if you return too soon you can have an acute increase in symptoms. If return to activity is too slow, you can have increased emotional dysregulation, deconditioning, reduced cerebrovascular control, increased HRV, headaches, body pain. On the other hand, for some, they had a delay in their concussion symptoms and then had poorer outcomes because they returned to play too quickly. Recent studies have shown early return to low intensity activity has best outcomes, which can be done with an active injury management protocol. In fact, those who took few steps/very minimal movement OR exercised vigorously had poorer outcomes than those with graded STEP protocols. When beginning RTP, it is recommended that the child begins with a light aerobic workout with no to minimal resistance, increase intensity gradually, evaluate symptoms after each day and re-assess plan. Exercise should be limited to 15 minutes at first, otherwise risk of PCS increases.

Unfortunately, some coaches and athletic staff are limited in their concussion recognition/management. The new messaging has been “when in doubt, sit them out” and “recognize and remove”, but the guidelines can be ambiguous and confusing. The concern is that up to 50% of children deny or fail to report concussion symptoms because they don’t recognize symptoms, don’t feel it is serious, don’t want to miss play time, or don’t want to let team down, and so they often don’t realize potential consequences for themselves and others. Additionally, there has been significant correlation between parental knowledge of concussion symptoms and children's willingness to report. Additionally, some athletes will experience anxiety about future concussions when returning to play. A very important note- return to play should not occur until return to learn has been initiated. In terms of education, return to learn (RTL) is recommended after 48 hours with minimal academic instruction. It is recommended that the child begins with half day and progress gradually to full, with the specific timeline dependent upon symptoms and severity, family involvement, and the treatment team, and the child should be involved in RTL plan as much as possible. Returning to work for teens, which for many requires driving, has concerned some parents and clinicians as well because of potential impairments to processing speed, working memory, and coordination; however, the research showed minimal differences in driving ability or reaction time.

So let’s talk about the best ways to assess concussion symptoms, both immediately, and long-term. Most important to know, there is no single test or battery is sufficient alone to evaluate concussion severity/effects but when the severity of concussion is accurately assessed, the recovery time is shorter, with reduced complications/PCS. Common assessment batteries to assess comprehensive cognitive function include:  Sport Concussion Assessment Tool, Sixth Edition (SCAT-6), The Headminder Concussion Resolution Index (CRI), CNS Vital Signs, The Axon Sports Computerized Cognitive Assessment Tool (CCAT), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), NeuroTech Insights Concussion Management, the King-Devick Test, and C3Logix. For more physical symptoms, the buffalo concussion treadmill test is helpful to establish thresholds of symptoms/discomfort. Additionally, the Balance Error Scoring System (BESS) and vestibular/ocular-motor (VOMS) assess visual, balance, and proprioceptive skills. There are also dual-task tests, which involve both motor and cognitive assessment, and are often able to detect effects months after initial injury by assessing gait speed, gait stability, cognitive efficiency and reaction time. One newer example is R2play, an assessment that simulates the complex demands of sports by using tablets, cognitive tasks (sequencing/inhibition), and running to assess overall cognitive and physical efficiency. So far there is good evidence of validity but the cost for clinicians and families is somewhat expensive at present ($3000), which can be a barrier to some. Finally, there is also the Rivermead Postconcussion Symptoms Questionnaire (RPSQ)- self-report measure.

Now let’s talk intervention. First off, it is very important to assess history and premorbid functioning (level of function prior to the injury) both because different cases can require very different treatment- you cannot assume any specific set of symptoms for each child, and also need to provide realistic expectations for recovery. Those who receive early intervention tend to experience a significantly shorter recovery time and reduced symptoms overall as well as reduced risk of PCS. It is also need to educate parents/caregivers/school team/coaches and normalize life and routine as much as possible for children. Common recommendations for PCS include: cognitive rehabilitation, behavioral modification, CBT, psychoeducation, vestibular or oculomotor rehab, exercise therapy, physiotherapeutic coaching, group-based compensatory cognitive training, goal-oriented attentional self-regulation training as well as and school modifications/accommodations for return. In terms of medications for mood, cognition, and or chronic pain, most commonly prescribed are SSRIs (antidepressants), carbamazepine (dizziness, headaches), valproic acid (headaches, neuroinflammation), guanfacine (attention), methylphenidate (attention), enzogenol (pine extract, fatigue and attention) as well as some new research on cerebrolysin (peptide) for cognitive benefit if started within 24 hours. In terms of the specific research, studies have shown positive benefit for rTMS (repetitive transcranial magnetic stimulation), CBT (cognitive-behavioral therapy), and reduction of blue light to help regulate sleep/mood. Inconsistent benefit have been found from mindfulness-based stress reduction (MBSR), head-eye vestibular motion therapy, and energy balance. Studies showed a lack of benefit from hyperbaric oxygen therapy (HBOT), botox, epidural, antibody therapy, and face/neck cooling.

Many families have expressed that different recommendations from different providers can make things complicated and confusing, as so many different providers can be involved because symptoms range across professions and body systems. The Collaborative Care Intervention Model (CCIM) links mental and medical providers and provides patient with a care manager, concussion-focused CBT, parenting skill training, and care management. CCIM has been most beneficial for those who historically “get lost” in the system (marginalized populations, low SES families). In fact, there are currently new pilot concussion health improvement programs (CHIP) in Seattle and Dallas, with promising results. All in all, having a multidisciplinary team, care management, early intervention, family support, and proper guidance on current effective interventions tends to result in the most positive outcomes and reduced risk of PCS.