Managing Return to Activities

Returning to daily home/community activities

Physicians should be cautious about allowing patients to return to driving, especially if the patient has problems with attention, processing speed, or reaction time. Patients should also be advised to get adequate sleep at night and to take daytime naps or rest breaks when significant fatigue is experienced. Symptoms typically worsen or re-emerge with exertion. Let any return of a patient’s symptoms be the guide to the level of exertion or activity that is safe.

Returning to school

Symptomatic students may require active supports and accommodations in school, which may be gradually decreased as their functioning improves. Inform the student's teacher(s), the school nurse, psychologist/counselor, and administrator of the student's injury, symptoms, and cognitive deficits.

Most kids and teens will only need help through informal, academic adjustments as they recover from a concussion. For kids and teens with ongoing symptoms, a variety of formal support services may be available to help them during their recovery. These support services may vary widely among states and school districts. The type of support will differ based on the needs of each student. Some of these support services may include:

• Response to Intervention Protocol (RTI)
• 504 Plan
• Individualized Education Plan (IEP)

A child or teen may feel frustrated, sad, and even angry because she or he cannot return to school right away, keep up with schoolwork, or hang out as much with their friends. Parents can talk with the child or teen about this and offer support and encouragement.

Returning to work

Return-to-work planning should be based upon careful evaluation of symptoms and neurocognitive status. To help expedite recovery from mTBI, patients may initially need to reduce both physical and cognitive exertion. Restricting work during initial stages of recovery may be indicated to help facilitate recovery. Repeated evaluation of both symptoms and cognitive status is recommended to help guide management considerations.

Returning to play (sports and recreation)

Guiding the recovery of individuals of any age with mTBI who participate in competitive or recreational activities requires careful management to avoid re-injury or prolonged recovery. Athletes engaged in collision sports require special management and evaluation to ensure full recovery prior to their return to play.

Managing an Athlete with a Concussion

For many healthcare professionals, the first chance to assess a young athlete with a suspected concussion will not be on the sidelines, but an office or emergency department. This examination will likely include a physical examination, covering cognition, neurology, balance, and most importantly, any signs of deteriorating neurological function.

When managing an athlete with concussion, a healthcare professional's management plan should cover both returning to school and to play, and should:

• Monitor both physical and cognitive activities
• Consider concussion history
• Be individualized to the athlete

Return to Play Progression

It is important for an athlete’s parent(s) and coach(es) to watch for concussion symptoms after each day’s return to play progression activity. An athlete should only move to the next step if they do not have any new symptoms at the current step. If an athlete’s symptoms come back or if he or she gets new symptoms, this is a sign that the athlete is pushing too hard. The athlete should stop these activities and the athlete’s medical provider should be contacted. After more rest and no concussion symptoms, the athlete can start at the previous step.

It is important to monitor symptoms and cognitive function carefully during each increase of exertion. Athletes should only progress to the next level of exertion if they are not experiencing symptoms at the current level. If symptoms return at any step, an athlete should stop these activities as this may be a sign the athlete is pushing too hard. Only after additional rest, when the athlete is once again not experiencing symptoms for a minimum of 24 hours, should he or she start again at the previous step during which symptoms were experienced.

The Return to Play Progression process is best conducted through a team approach and by a health professional who knows the athlete's physical abilities and endurance. By gauging the athlete's performance on each individual step, a healthcare professional will be able to determine how far to progress the athlete on a given day. In some cases, the athlete may be able to work through one step in a single day, while in other cases it may take several days to work through an individual step. It may take several weeks to months to work through the entire progression.

Before the start of the season, healthcare professionals should learn about state, league, or sports governing body's laws or policies on concussion. Some policies may require health care professionals to take a training program or provide written clearance as part of the return to play process for young athletes.

When to refer to a specialist

Remember, most people will recover quickly and fully following a concussion. Some will have symptoms for weeks or longer. Healthcare professionals should consider referral to a concussion specialist if:

1. The symptoms worsen at any time,
2. The symptoms have not gone away after 2 to 4 weeks, or
3. The patient has a history of multiple concussions or risk factors for prolonged recovery. This may include a history of: migraines, depression, mood disorders, or anxiety, as well as developmental disorders such as learning disabilities and ADHD.