Premature Return to Play After Concussion Has Decreased

Pam Harrison

May 02, 2022

Rates of premature return to play (RTP) among student athletes following a sport-related concussion (SRC) have dropped substantially since 2011, according to a recent chart review. Rates of premature return to learn (RTL) are essentially unchanged, however.

“Delay in recovery is the major reason why it’s important not to RTL or RTP prematurely,” James Carson, MD, associate professor of family and community medicine, University of Toronto, Toronto, Ontario, Canada, told Medscape Medical News.

“That delay in recovery only sets students further back in terms of the stress they get from being delayed with their schoolwork — they could lose their year in school, lose all their social contacts. So, there are a number of psychosocial issues that come into play if recovery is delayed, and that is what premature RTL and premature RTP will do — they delay the student’s recovery,” he emphasized.

The study was published in the March 2022 issue of Canadian Family Physician.

Differences by Sex

The study involved 241 students who had 258 distinct cases of SRC. The researchers defined premature RTP and RTL as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient’s RTP or RTL. Between 2011 and 2016, 26.7% of students had evidence of premature RTP, while 42.6% of them had evidence of premature RTL, the authors note.

Compared with findings from an earlier survey of data from 2006 to 2011, the incidence of premature RTP dropped by 38.6% (P = .0003). In contrast, symptoms associated with premature RTL dropped by only 4.7% from the previous survey. This change was not statistically significant.

There was also a significant difference between males and females in the proportion of SRC cases with relapse of symptoms. Relapse occurred in 43.4% of female athletes with SRC versus 29.7% of male athletes with SRC (P = .023).

Female athletes also had significantly longer times before being cleared for RTP. The mean time was 74.5 days for females, compared with a mean of 42.3 days for male athletes (P < .001). “The median time to RTP clearance was nearly double [for female athletes] at 49 days vs 25 days [for male athletes],” wrote the authors.

The rate of premature RTL was also higher among secondary school students (48.8%), compared with 28% among elementary students and 42% among postsecondary students.

More Concussions Coming?

Before the first consensus conference, organized by the Concussion in Sport Group in 2001, management of concussion was based on rating and grading scales that had absolutely no medical evidence to support them, said Carson. After the consensus conference, it was recommended that physicians manage each concussion individually and, when it came to RTP, recommendations were based upon symptom resolution.

In contrast, there was absolutely nothing in the literature regarding how student athletes who sustain a concussion should RTL. Some schools made generous accommodations, and others none. This situation changed around 2011, when experts started publishing data about how better to accommodate student athletes who have a temporary disability for which schools need to introduce temporary accommodations to help them recover.

“Recommendations for RTP essentially had a 12-year head-start,” Carson emphasized, “and RTL had a much slower start.” Unfortunately, Carson foresees more athletes sustaining concussions as pandemic restrictions ease over the next few months. “As athletes RTP after the pandemic, they just will not be in game shape,” he said.

“In other words, athletes may not have the neuromuscular control to avoid these injuries as easily,” he added. Worse, athletes may not realize they are not quite ready to return to the expected level of participation so quickly. “I believe this scenario will lead to more concussions that will be difficult to manage in the context of an already strained healthcare system,” said Carson.

A limitation of the study was that it was difficult to assess whether all patients followed medical advice consistently.

"Very Positive Shifts"

Commenting on the findings for Medscape Medical News, Nick Reed, PhD, Canada research chair in Pediatric Concussion and associate professor of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Ontario, Canada, said that sports medicine physicians are seeing “very positive shifts” in concussion awareness and related behaviors like providing education, support, and accommodations to students within the school environment. “More and more teachers are seeking education to learn what a concussion is and what to do to best support their students with concussion,” he said. Reed was not involved in the current study.

Indeed, this increasing awareness led to the development of a concussion education tool for teachers — SCHOOLFirst — although Reed did acknowledge that not all teachers have either the knowledge or the resources they need to optimally support their students with concussion. In the meantime, to reduce the risk of injury, Reed stressed that it is important for students to wear equipment appropriate for the game being played and to play by the rules.

“It is key to play sports in a way that is fair and respectful and not [engage] in behaviors with the intent of injuring an opponent,” he stressed. It is also important for athletes themselves to know the signs and symptoms of concussion and, if they think they have a concussion, to immediately stop playing, report how they are feeling to a coach, teacher, or parent, and to seek medical assessment to determine if they have a concussion or not.

“The key here is to focus on what the athlete can do after a concussion rather than what they can’t do,” Reed said. After even a few days of complete rest, students with a concussion can gradually introduce low levels of physical and cognitive activity that won’t make their symptoms worse. This activity can include going back to school with temporary accommodations in place, including shorter school days and increased rest breaks. “When returning to school and to sport after a concussion, it is important to follow a stepwise and gradual return to activities so that you aren’t doing too much too fast,” Reed emphasized.

The study was conducted without external funding. Carson and Reed reported no conflicts of interest. 

Canadian Family Physician. Published March 2022;68:e87-e91. Source.

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