Concussion series, Part 2: Management and Return to Play

**Disclaimer**: I am not a representative of Complete Concussion Management Institute (CCMI), nor am I endorsed by them. I am a Certified Complete Concussion Management Practitioner (CCCMP) through CCMI, but am not paid to present this material. The following post is of my own, and does not represent opinions of anyone but myself.

Now that we have the basic physiology of concussions out of the way, lets talk management and return to play. This topic will be split into 2 parts; A and B. So an athlete comes off the field and tells you they don’t feel good, with c/o headache, dizziness, blurred vision, and nausea. They say they took a hit a few plays back but didn’t lose consciousness. Now what?

Until about 2012, the NFL had been using guidelines from the American Academy of Neurology’s 1997 Practice Parameters, which allowed an athlete to return to play if their symptoms resolved in 15 min. It also graded concussion severity based on loss of consciousness (or not) which we know, now, is not true. They also used to take the players and put them in a dark room to “help alleviate” symptoms – but we know that that also does not work, nor is it evidence based. There used to be a protocol where following a hit, in order to determine if they can return to play that day following resolution of symptoms, the athlete would be asked to do squats (bodyweight) and pushups and some battery of exertional movements. Increased body temperature has been shown to increase glutamate levels in the body – and from what we know about glutamate in Part 1 of this series, increased glutamate increases Ca+2 into the cells which is the main problem with concussions.

However, thankfully the 2012 Zurich Consensus happened and now there are rules against same day return to play if the athlete has either a clear MOI and/or exhibits signs and symptoms of having sustained a concussion.

So the athlete comes to you with c/o symptoms that appear to be from a concussion with an MOI. If the athlete is conscious (the play did not just happen leaving them on the ground and you do not need to activate EMS, and/or you’ve already ruled out the possibly of a spinal cord injury) you’d take them to the side and ask them some orientation questions and go through a sideline assessment such as the SCAT3. You’d continue to monitor their symptoms over the course of the next few hours – DO NOT let the athlete sleep for at least 3 hours. And when they do sleep have someone (or do it yourself if you’re traveling with the team) wake them up every 2-3 hours. The point is that while rest would be nice, you want to monitor their symptoms and make sure they don’t get worse. Make sure you rule out a hemorrhage – send to the ER for imaging if necessary or suspected.

If the athlete is coming to you a day or so after the hit, and you are performing the initial evaluation – make sure to do a full cranial nerve screen and neuro exam. Again, we want to rule out other serious pathology as well as make sure that their symptoms have not gotten worse. Education and reassurance is key in treating athletes with concussions – especially with the media giving it so much attention. There is a large psychological component of concussions and you need to address that at each and ever visit, starting with the eval.

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Many of you are familiar with the above chart for return to play. In order to progress from one stage to the next, the athlete needs to have no symptoms for at least 24 hours. If they get symptoms in the next stage, you regress them back one step until asymptomatic. The first step is brain rest. This gets tricky and needs to be handled with care otherwise you will be feeding into the psychological aspect of concussions. You want rest, but not for more than 3-4 days. Max, 14 days is the point at which you need to start encouraging them to perform light physical activity (stage 2). Many physicians will tell the athlete to rest until they have no symptoms – a month may go by and they are still having symptoms (Now, Post Concussive Syndrome). This can increase their anxiety levels and increase their risk of depression as well as decreased overall physical conditioning.  14 days is our turning point, at which, rest can become detrimental to the athlete. Exercise is the most important rehab intervention and has the following effects: increase brain derived neurotropic factor, increase blood flow, increased sense of control (for the patient), improving neurocognition, decreasing inflammation to name a few. So the idea is that you want them to exercise and progress to stage 2 as soon as possible, after an initial resting phase.

One point I’d like to stress is that most athletes will recover from their physical symptoms around 8 days, however research shows that METABOLIC RECOVERY can take up to 30 days in some cases. Therefore, I find the above RTP guidelines too simplistic in some cases because it does not TEST physical capabilities nor does it apply to work/school scenarios. Rather it is based on a reactionary scheme – if they do not have symptoms, progress, if they do then regress. But there is no mention on how to TEST the athlete to know if they can progress/regress.

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Physical exertion is required to stress the body and see how the athlete reacts – do they get onset of symptoms with a treadmill test or a bike test? At CCMI their RTP guidelines are a little more detailed and has 3 more steps. For example, in their RTP guidelines step 3 allows an athlete to return to a half day of school/work with restrictions. It is important to not only stress return to sport, but also return to daily life, which the general guidelines do not make much mention of.

Stay tuned for follow up posts that will discuss Post Concussion Syndrome, Second Impact Syndrome, and Physical Therapy interventions for the concussed athlete.


Thomas, D. G. MD, MPH et al Benefits of strict rest after an acute concussion: A Randomized Trial. PEDIATRICS 135(2); 2015

McCulloch, K. L. et al Development of Clinical Recommendations for Progressive Return to Activity After Military Mild Traumatic Brain Injury: Guidance for Rehabilitation Providers. J. Head Trauma Rehabil 30(1); 56-67

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