Overview
Definition:
Return-to-play (RTP) refers to the process of safely reintegrating an athlete back into training and competition following a concussion
A graduated protocol is a structured, stepwise approach designed to ensure the athlete is symptom-free and neurologically stable before full return
This is critical in pediatrics due to the developing brain’s unique vulnerability and recovery patterns.
Epidemiology:
Concussions are common in pediatric athletes, with incidence varying by sport and age group
adolescent athletes in contact sports have the highest risk
While most children recover fully, a significant minority may experience prolonged symptoms, highlighting the need for careful RTP management.
Clinical Significance:
Inadequate or premature return to play post-concussion in children and adolescents can lead to prolonged recovery, increased risk of subsequent concussions (with potentially more severe consequences), and long-term cognitive or emotional sequelae
Adherence to evidence-based graduated protocols is paramount for patient safety and optimal neurological recovery.
Age Considerations
Infants Toddlers:
Concussion diagnosis is challenging due to communication limitations
Signs may be subtle, including irritability, changes in feeding or sleep patterns, loss of developmental milestones
RTP requires strict parental supervision and avoidance of all stimulating activities.
School Aged Children:
Children in this age group can articulate symptoms but may struggle with sustained attention or memory recall
School accommodations are often as important as athletic RTP
Return to learning precedes return to play.
Adolescents:
Adolescents can typically provide detailed symptom reporting but may face peer pressure or desire to return to play quickly
Risk-taking behaviors can increase
They are more susceptible to second impact syndrome if RTP is poorly managed.
Clinical Presentation
Symptoms:
Headache
Dizziness or balance problems
Nausea or vomiting
Sensitivity to light or noise
Feeling foggy or groggy
Difficulty concentrating or remembering
Blurred or double vision
Sleep disturbances (more than usual or trouble sleeping)
Feeling more emotional, irritable, sad, or nervous.
Signs:
Appearing dazed or stunned
Forgetting instructions
Moving clumsily
Answering questions slowly
Loss of consciousness (though not required for diagnosis)
Changes in mood, behavior, or personality
Persistent vomiting
Seizures.
Diagnostic Criteria:
Diagnosis of concussion is primarily clinical, based on a history of a blow or jolt to the head/body causing rapid head movement, and the presence of at least one of the following: neurological signs or symptoms (e.g., confusion, amnesia), cognitive impairment, or behavioral change
No specific imaging is required for diagnosis but may be used to rule out structural injury.
Diagnostic Approach
History Taking:
Mechanism of injury (how, when, where)
Immediate symptoms (headache, dizziness, LOC, amnesia)
Post-injury symptoms (development over minutes/hours)
Any previous concussions or head injuries
Presence of red flags: worsening headache, repeated vomiting, seizures, focal neurological deficits, significant confusion, slurred speech, pupil asymmetry.
Physical Examination:
General appearance
Vital signs
Neurological examination: cranial nerves, motor strength, sensation, reflexes, coordination (finger-to-nose, heel-to-shin), gait, balance (Romberg test)
Assessment for neck pain or injury
Brief cognitive screening (orientation, memory).
Investigations:
Typically, no routine investigations are needed for acute concussion if red flags are absent
CT or MRI brain may be indicated if: severe headache, repeated vomiting, focal neurological signs, seizure, suspected skull fracture, altered mental status, or significant mechanism of injury suggesting other intracranial pathology
EEG is rarely indicated for concussion itself.
Differential Diagnosis:
Intracranial hemorrhage (subdural, epidural, parenchymal)
Skull fracture
Cervical spine injury
Migraine
Vestibular dysfunction
Metabolic derangements
Anxiety/panic attack
Post-traumatic stress disorder
Retinal detachment.
Management
Initial Management:
Immediate removal from play
Assessment for red flags by trained medical professional
If red flags present, emergent evaluation in an emergency department
If no red flags, relative cognitive and physical rest for 24-48 hours, followed by a gradual increase in activity as tolerated.
Rest Protocol:
Initial period of relative rest (avoiding strenuous physical and cognitive activities) for ~24-48 hours is recommended
This is not complete bed rest
light activities that do not provoke symptoms are encouraged
Gradually increase cognitive load (schoolwork, screen time) and physical activity as tolerated, ensuring each step does not worsen symptoms.
Pharmacological Management:
No specific medication for concussion
Analgesics like acetaminophen may be used for headache
Avoid NSAIDs initially due to theoretical risk of bleeding, especially if coagulopathy is suspected
Medications for nausea or sleep disturbances may be considered on a case-by-case basis
Avoid medications that cause sedation or impair cognition.
Supportive Care:
Adequate sleep
Hydration and nutrition
Gradual reintroduction to school and social activities
Psychological support for anxiety or mood changes
Education for athlete and family regarding symptom monitoring and RTP process.
Graduated Return To Play Protocol
Introduction:
The graduated RTP protocol involves several stages, requiring the athlete to be symptom-free at each stage before progressing to the next
Each stage typically lasts 24 hours
Progression is halted if symptoms reappear, and the athlete returns to the previous symptom-free stage.
Stage 1 Rest:
Symptom-limited physical and cognitive rest
Aim is to allow acute symptoms to subside
Focus on avoiding activities that significantly exacerbate symptoms
Duration: ~24-48 hours.
Stage 2 Light Aerobic Exercise:
Introduction of light aerobic exercise (e.g., walking, stationary cycling)
Aim is to increase heart rate and blood flow
Exercise should not provoke symptoms
Duration: ~24 hours.
Stage 3 Sport Specific Exercise:
Introduction of sport-specific drills in a controlled environment (e.g., jogging, skating, passing drills)
No contact or collision
Focus on movement patterns
Duration: ~24 hours.
Stage 4 Non Contact Training:
Participation in full team practices but without contact or collision (e.g., positional drills, controlled scrimmages)
Aim to improve coordination and reaction time
Duration: ~24 hours.
Stage 5 Full Contact Practice:
Return to normal training activities, including contact and collision drills, after medical clearance
This allows coaches to assess recovery in a game-like situation
Duration: ~24 hours.
Stage 6 Return To Play:
Return to competition/game play
Athlete should be completely symptom-free and have undergone all previous stages without exacerbation
Medical clearance from a qualified healthcare professional is mandatory.
Complications
Prolonged Symptoms:
Post-concussion syndrome (PCS) characterized by persistent headache, dizziness, cognitive difficulties, and emotional lability lasting beyond the expected recovery period (typically weeks to months).
Second Impact Syndrome:
Rare but potentially fatal complication occurring when a second concussion is sustained before the brain has adequately recovered from the first
Leads to rapid, severe brain swelling (diffuse cerebral edema) with high mortality and morbidity.
Increased Risk Of Reinjury:
Returning to play too soon significantly increases the risk of sustaining another concussion, which may be more severe and lead to longer recovery
Impaired reaction time and judgment post-concussion contribute to this risk.
Long Term Sequelae:
In some cases, particularly with multiple concussions or severe injuries, long-term issues such as chronic headaches, memory problems, attention deficits, and mood disorders may persist.
Prognosis
Factors Affecting Prognosis:
Age (younger children may take longer to recover)
History of previous concussions
Severity of initial symptoms
Presence of pre-existing conditions (e.g., migraine, learning disabilities, mental health issues)
Delay in seeking medical attention
Adherence to RTP protocol.
Outcomes:
The majority of pediatric concussion patients recover fully within 2-4 weeks with appropriate management
However, a significant minority may experience prolonged recovery or lasting symptoms
Early and appropriate intervention is key to optimizing outcomes.
Follow Up:
Regular follow-up with a healthcare provider experienced in concussion management is crucial, especially for athletes with prolonged symptoms or those returning to high-risk sports
This ensures adherence to the RTP protocol and monitors for any developing complications.
Key Points
Exam Focus:
Emphasis on the graduated RTP protocol stages and the rationale behind each
Red flag symptoms requiring immediate emergency evaluation
Differentiating concussion from more severe intracranial pathology
Age-specific considerations in pediatric concussion management.
Clinical Pearls:
Always err on the side of caution
"when in doubt, sit them out." Educate athletes and parents thoroughly about concussion symptoms and the RTP process
Return to learn often precedes return to play
Symptom exacerbation is a sign to regress to the previous symptom-free stage.
Common Mistakes:
Underestimating concussion severity in young children
Premature return to play due to competitive pressure
Relying solely on sideline screening tools without clinical judgment
Not adequately addressing cognitive aspects of recovery (e.g., school)
Ignoring psychological impact of concussion.