Concussion Guidelines Are Just That: Guidelines

The ACSM statement:

• Endorses the widely-held view that athletes with significant, persistent or worsening signs and symptoms should not return to play the day of injury (note: most experts now recommend, and at least 28 states and the District of Columbia now bar, same day return to play in any case of suspected concussion, no matter how "mild" it might be considered to be); 
• Recognizes that "for other athletes with concussion, significant controversy exists for a same-day RTP decision," but that the "safest course of action" was to "hold an athlete out."  [Note: a consensus has developed since 2006 barring same-day-return-to-play in the case of any suspected concussion].
• Recommends use of "progressive aerobic and resistance exercise challenge tests before full RTP," (akin to the stepwise RTP guidelines set forth in the Vienna, Prague and Zurich¹ consensus statements) and consideration of other factors affecting RTP for an individual athlete, including age, previous concussion history, whether repeated concussions had occurred with progressively less impact force, the sport, and whether the athlete had any learning disabilities (akin to the so-called "modifying factors" for concussion listed in the 2008 Zurich consensus statement ).

Just Guidelines

Parents should remember that, regardless of which set of guidelines their child's school or sports program follows, the guidelines are just that: guidelines, not ironclad rules. Each case should be reviewed, ideally by a medical doctor with training in concussons, on an individual basis to determine whether their child is able to return safely to sport.

No matter what guidelines are followed, in making return to play decisions, the following factors should be considered:

• The severity of the current injury (especially loss of consciousness longer than 1 minute)
• How long the symptoms persist (including persistent symptoms with exertion)(when an athlete's symptoms persist, he or she is classified as having a condition called post-concussion syndrome (PCS).
• Whether there has been prolonged cognitive impairment (e.g. memory, reaction time, concentration problems)
• Whether the athlete has learning disabilities (ADD, ADHD etc.)
• Whether the athlete has suffered repeated concussions over time, and if so, the number, severity, proximity in time to current injury.
  • An athlete with a previous concussion during the season is at 3 to 4 time's greater risk for suffering a second concussion. The risk of concussion increases further after each subsequent concussion.
  • For athletes who have suffered three mild/simple concussions or two moderate-severe/complex concussions in the same season, experts advise that they not be permitted to return to play again that season.[Note: this is the approach taken by Dr. Robert Cantu in his most recently revised return to play guidelines].
• The sport the athlete is playing. An athlete participating in a non-contact, low-risk sport can, in all likelihood, be returned to play sooner than an athlete returning to a high-risk, collision sport, such as football, boys' ice hockey, boys' lacrosse or wrestling.
• Whether repeated concussions are occurring with progressively less impact force
• The athlete's age (a child's developing brain is believed to react differently to trauma than a mature brain).

1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 20090: 43:i76-i84.