Following adoption by the American Academy of Pediatrics adopted (Halstead, 2010) of the return-to-play (RTP) guidelines proposed by the Third International Conference on Concussion in Sport (ICCS) (McCrory, 2009), a multidisciplinary sports medicine team at Children's Healthcare of Atlanta (CHA) has now proposed sport-specific guidelines for ten sports known to put young athletes at the highest risk for concussion, including girls' lacrosse. (May KH, 2014)

The guidelines set out below add an additional moderate activity step as a new step three in the ICCS's six-step RTP process for athletes recovering from a concussion. The added step is to test an athlete's tolerance for low-weight, high repetition resistance training, which can increase intracranial pressure and exacerbate post-concussion symptoms.

To simulate sport specific movements, they also modify steps three and four of the original six-step RTP guidelines (now steps four and five) to include non-contact and limited contact drills specific to girls' lacrosse.

The new guidelines continue the step-wise progression of the ICCS RTP guidelines, permitting youth athletes to advance to the next step only if they remain symptom-free for 24 hours after exercise. As before, if symptoms re-occur with exercise, the progression should be stopped and the athlete returned to the previous phase where symptoms did not occur. Athletes may begin the RTP progression only after they are symptom free, and have achieved a full return to school, with academic accommodations (Halstead, 2013) discontinued.

As in the original RTP guidelines, the final RTP determination should only occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions, as is now required by law - at least for high school athletes - in 48 states and the District of Columbia.

Return to Physical Activity Following Concussion - Girls' Lacrosse

Clear up confusion

While recognizing the "significant strides" made in recent years in the management and care of concussed athletes, lead author Keith May, Clinical Outcomes Project Manager of the Sports Medicine Program at CHA, noted that "there continues to be a lot of confusion among, athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population."

The proposed girls' lacrosse-specific RTP guidelines, May said, were designed to help eliminate that ambiguity and help further promote adherence to the RTP guidelines in order to avoid returning young girls' lacrosse players too soon after concussion, which increases the risk of a second concussion, or, worse, a catastrophic brain injury from second impact syndrome.

May notes that adherence to even the current general return to play recommendations "continues to be a challenge in the pediatric and adolescent sporting community, pointing to two 2009 studies, the first (Yard, Comstock 2009) finding that one in six athletes failed to follow a standardized RTP guideline, and thus frequently returned to their sport prematurely, and the second (Hollis et al, 2009) reporting that only 66 of 296 rugby athletes with suspected concussions returned to play with medical clearance. An earlier study (Sye, 2006) reported that 145 of 187 rugby players were only compliant with the initial rest period.

No guidelines for pre-adolescents

"Of special concern," writes May and his colleagues, is that there are currently no suggested RTP guidelines for athletes under the age of 13. Because younger athletes tend to report concussion symptoms differently from older athletes and adults, age-appropriate physical and cognitive testing and symptom checklists (such as the Child-SCAT3 are recommended. The only consensus among concussion experts, May says, is that the different physiological response of children and adolescents to concussion, including longer recovery times and the risk of diffuse cerebral swelling (commonly referred to as second impact syndrome) from a second hit before the developing brain has healed, require that concussions in such athletes be managed more conservatively, and that clinicians be prepared to extend the recovery timeline.

As with older athletes, the actual recovery time may vary, based on the individual patient. "It is important to recognize," writes May, "that the mechanisms of concussive injury and force of collision vary among sports," and that for "this reason, every concussion is unique."  RTP guidelines should utilize symptom reports, as well as cognitive and balance examination data to track recovery, which, May says, will assist in developing detailed understand regarding how and when to return pediatric athletes back to their sports activities.

Additionally, RTP guidelines may need to be adjusted for those who have experienced a prior head injury. The study notes that multiple authors have described that those who have suffered a prior injury have up to a 5.8 fold increased rate of re-injury. Therefore, treating an athlete with multiple concussions involves emphasizing the need to consider the long-term consequences and recovery prior to RTP.

Caution in adoption urged

May and his colleagues concede that further research is needed to validate the proposed guidelines and their potential impact on return to play adherence and overall success.

Several top concussion experts not involved with the new guidelines agreed. "I think it is a good idea to understand how the International Consensus guidelines need to be tailored to children and to various sports, which is currently being done on a case-by-case basis since every concussion is unique. I am not sure whether providing specific guidelines for each sport will help produce better outcomes," said Dr. Rosemarie Scolaro Moser, a sports neuropsychologist, researcher, and Director of the Sports Concussion Center of New Jersey.

"Ultimately we want to be sure that each child and adolescent is managed individually. Athletic trainers are the best to provide such guidance and can tailor the guidelines to youth and specific sports. Everyone needs to remember that these new guidelines as well as the International ones have not been researched to determine their effectiveness. It will be interesting to see if the wider group of concussion experts will endorse and promote such sport specific guidelines by consensus," Moser said.

R. Dawn Comstock, PhD. associate professor in the Department of Epidemiology at the Colorado School of Public Health, agreed with Dr. Moser. She noted that the Children's Healthcare of Atlanta sport-specific RTP guidelines "are merely one set of RTP guidelines (for other guidelines, click here) put out by one of many different organizations, albeit one of the only ones to be sport-specific," She urged against a premature endorsement of the CHA RTP guidelines, "given the lack of evidence to support their superiority relative to any of the others out there."

1. Halstead, ME, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents. Pediatrics. 2010;126(3):597-615 (http://pediatrics.aappublications.org/content/126/3/597.full.pdf+html)

2. Halstead ME, et al. Clinical Report: Returning to Learning Following a Concussion. Pediatrics 2013;doi:10.1542/peds.2013-2867 (epub October 27, 2013)( http://pediatrics.aappublications.org/content/132/5/948.full.pdf+html)

3. Hollis SJ, Stevenson MR, McIntosh AS, et al. Incidence, risk, and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players. Am J Sports Med. 2009;37:2328-33.

4. May KH, Marshall DL, Burns TG, Popoli DM, Polikandriotis JA. Pediatric Sports Specific Return to Play Guidelines Following Concussion. Int'l J Sports Phys. Therapy. 2014;9(2):242-255).

5. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M. et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009; 43(Suppl. 1):i76-i90.

6. Sye G, Sullivan SJ, McCrory P. High school rugby players' understanding of concussion and return to play guidelines. Br J Sports Med. 2006;40:1003-5.

7. Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005-2008. Brain Inj. 2009;23:888-98.