Concussion Return to Activity – the what, how & when
The American Medical Society of Sports Medicine recently published a position statement on concussions in sport.1 This statement covers many aspects of concussion management. I will be focusing only on their return to activity recommendations and how, if at all, they alter my current practices that follow the Berlin Consensus Statement of 2016. 2 According to the studies referenced, 80-90% of older adolescents and adults resolve their sports concussions (number of previous concussions not specified) in 2 weeks. When it comes to younger individuals (no definition provided) it takes about 4 weeks to resolve. The best predictors of recovery are the number and severity of acute and subacute symptoms. Subacute headaches and depression are risk factors for prolonged symptoms beyond 1 month. Cited research by Leddy J. et al. indicates that lower symptom-limited heart rate thresholds during graded treadmill testing, are additional predictors of prolonged recovery.3
This positional statement advocates using the term Persistent Post Concussion Symptoms (PPCS) where the timeframe is greater than 2 weeks for older adolescents / adults and greater than 4 weeks for younger youth. Most clinicians use 3 months as the bench mark for a concussion vs. Post-concussion Syndrome. The authors prefer the PPCS title and timeframe rather than Post-concussion syndrome (PCS) because they say the diagnostic criteria for PCS are often not used consistently. Further complicating the matter are differences between the ICD-10 and DSM V diagnostic criteria for PCS in the numbers, type and lengths of symptoms.
Unchanged from the Berlin Consensus document are the following:
- 24-48 hours of physical and cognitive rest.
- Thereafter the patient should be instructed to gradually increase activity while keeping below the symptom-exacerbation level.
With respect to PPCS (i.e. > 1 month), the Positional Statement has additional recommendations concerning return to activity:
- Ongoing symptoms may or may not be concussion related. They may be as much, or more, related to a worsening of pre-concussion issues (e.g. neck, migraine and psychological).
- Cognitive and physical activity / exercise undertaken or prescribed should not worsen symptoms.
- Previously Leddy et al. had recommended doing grade exercise testing (e.g. BCTT) no sooner than 3 weeks post injury. The BCTT or equivalent may now be safely done in adolescents as early as 1 week post injury.3 Other ages were not tested, but as adolescents, particularly younger youth, are as a group more vulnerable, it stands to reason that this timeframe would extend to adults.
- Individualized symptom-limited “return to learn” strategies should be employed.
- Progressive graduated return to sport & play should be used, with at least 24 hours without return of symptoms before advancing to the next stage.
- There are no widely accepted return-to-driving protocols, other than a knowledgeable MD discussing risk management on a case by case basis. (Note: in Ontario, restriction & return to driving instructions can only be made by an MD or Nurse Practitioner).
- According to the authors, Second Impact Syndrome is rare and controversial and seems mostly limited to pediatric and adolescent individuals. Beyond this, concussed children are not discussed and the senior population group is not referenced. (Note: Ontario’s Rowan’s Law about concussion safety and return to play mandates a much stricter interpretation of when and how children and youth can return to sport.)
- There are no evidence-based criteria for retiring an athlete from a given sport(s). The positional statement says many factors need to be included: length of resolution, developing concussions with less and less force, increasing severity of concussions, post-traumatic seizures, and persistent neurological deficits. In my opinion this also needs to be done by a knowledgeable MD rather than a rehab clinician.
If it is true that the vast majority of individuals recover within 1 month (presumably having had just 1 concussion), it is also true that the vast majority of patients I see as clinician have symptoms for much longer than 1 month. The problem then becomes how to interpret these recommendations for the more chronic patients I generally see (i.e. from 4 week to years). Do I continue to advocate avoidance of symptom worsening for life? If so, then I am likely condemning these patients to a very restricted life. If this approach were used with chronic pain patients, it would restrict them to total inactivity. This is why I feel the Post-concussion Syndrome and its timeframe of 3 month is still very relevant and useful. If by 3 months, in other words 3 times the period for physiological recovery period used in PPCS, the patient is still symptomatic, I start to lessen the restriction on their activity. Admittedly this timing is a bit arbitrary, but given our present level of understanding of chronicity, it has a very necessary safety buffer built-in. For this reason, I will continue to use clinically the following symptom framework handout for my Concussion vs. Post-concussion Syndrome patients:
- Symptom Framework for Concussions (up to 3 months)
You want to follow 4 rules of thumb when dealing with your symptoms:
- If you have a given symptom, for example a headache, try not to worsen the symptom by the activities you undertake.
- If you don’t have a given symptom, for example dizziness, try not to bring it on by the activities you undertake.
- Pay attention also to your symptoms the next day. If you wake up with stronger symptoms, this means you have overdone it with the previous day’s activities.
- While doing specific exercises, your symptoms may increase. This is OK so long as the increase is tolerable for you, and so long as your symptoms come back to where they were prior to doing the exercise within about 10 minutes. If not, you will need to decrease the difficulty, repetitions, duration, etc., so it doesn’t break this 4th
- Symptom Framework for Post-concussion Syndrome (longer than 3 months)
Most concussions are considered to be resolved within 3 months. However a small percentage of individuals with concussions go on to develop something called Post-concussion Syndrome (PCS). The first thing to understand about PCS is that it should not be considered as just a long concussion. It is best thought of as a different condition altogether, one that sometimes emerges following a concussion. PCS therefore needs to be treated differently from a concussion. How long PCS will last is highly variable to both the individual and their particular concussion incident. Experiencing PCS symptoms does not mean you are inflicting damage on yourself or prolonging your recovery. It is even more important with PCS, a more chronic condition than a concussion, to understand that
HURT DOES NOT EQUAL HARM
The following symptom framework for Post-concussion Syndrome is based that of the neurologist Dr Jeffrey Kutcher’s presentation at the UHN Traumatic Brain Conference, 2017 (with my own modifications in red).
For PCS you want to use 4 approaches when dealing with your symptoms:
- If you experiencing annoying symptoms, your approach is to ignore them.
- If you are experiencing aggravating symptoms, your approach is to try to tolerate them.
- If on the other hand, your symptoms become intolerable, or they come on and then last overnight, you need to note this and try to change your activities (in degree and/or duration), so that your symptoms are merely annoying or aggravating the next time around.
- Avoidance of activities is not usually the best policy. Moderating your activities is a better approach.
Your PCS goal is to gradually, step-wise increase your activity tolerance, neither being too timid, nor too aggressive. This is the best way to get back to both what you need to and want to do.
In my view, these 2 frameworks incorporate the best of both the PPCS and PCS approaches.
- Harmon K. et al. American Medical Society for Sports Medicine Position Statement on Concussion in Sport. Clinical Journal of Sports Medicine, 2019 Mar; 29 (2): 87-100.
- McCrory P. et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017; 51: 838–847.
- Leddy. J. et al. Safety prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial. Clinical Journal of Sports Medicine, 2018 Jan; 28 (1):13-20