5 Key concussion messages

Every 4 years concussion researchers from around the world gather.  Their goal: to provide an authoritative report on the current knowledge about the causes and treatment for concussions and brain injuries.

Message #2 deals with “return-to-learn”.  Note that this suggests that return-to-learn and return-to-play need to be handled separately, based on the student’s specific symptoms.

The most recent report is from 2017, and includes 5 key messages:

1- Prolonged rest until all symptoms resolve is no longer recommended:

After an initial short rest period lasting 24-48 hours, the early introduction of light cognitive and physical activity can be initiated as long as the activity does not exacerbate symptoms (sub-threshold activities).

2- A gradual return-to-school (cognitive activity) strategy has been detailed:

A 4-step graduated return-to-school strategy has been proposed. It is recommended that children and adolescents return to full time school activities before they return to sports; however, initiation of physical activity can occur prior to a complete return to school.

3- Progression through the recovery process should be guided by the symptom exacerbation threshold:

Gradual return to sub-threshold cognitive activities and low risk individual physical activity can progress as long as they don’t increase symptoms. However, complete symptom resolution should be achieved before participating in activities placing the individual at risk of concussion (ex: non-contact training drills). Also, the statement emphasises the importance of respecting a minimum of 24 hours between each step of the return to sport protocol, and obtaining medical clearance before resuming sport-specific activities that may place the individual at risk of concussion.

4- The use of baseline testing is not necessary:

The Sport Concussion Assessment Tool 5 (SCAT5) is considered useful to help health care professionals assess for the possible presence of a concussion immediately after an injury, but should not be used as a stand-alone method to diagnose a concussion. The utility of the SCAT5 as a screening tool appears to decrease significantly 3–5 days after injury. SCAT5 baseline testing is not necessary for interpreting post-injury scores. In addition, based on current evidence, the widespread routine use of baseline computerized neuropsychological testing is not recommended in children and adolescents. When these tests are used in the post-injury setting they should optimally be performed and interpreted by an accredited neuropsychologist.

5- Persistent post-concussive symptoms should be reassessed to identify associated conditions and define an individualised treatment plan:

The strongest and most consistent predictor of slower recovery from concussion is symptom severity in the initial few days after injury. The symptom checklist demonstrates clinical utility in tracking recovery. Based on the evolution of most concussions, the notion of “persistent concussion symptoms” has been re-defined as greater than 2 weeks for adults and greater than 4 weeks for children. When symptoms persist beyond this expected timeframe, medical re-evaluation should be obtained to develop an individualised treatment plan. Attention should be given to
recognising and managing of the following conditions: autonomic system dysfunction, physical deconditioning, cervical spine problems, vestibular dysfunction and mood problems. Care of patients with persistent postconcussive symptoms should optimally be managed in a multi-disciplinary setting by a team of healthcare providers including a physician with experience in sport related concussions.