Over the past several years, there has been an increased focus on the perils of concussion, particularly to the still-developing brain. Two of the clearest reasons to promote proper recovery are to reduce the risk of re-injury during a period of brain vulnerability that could result in second impact syndrome, which can be life-changing, if not fatal; and to reduce the likelihood of post-concussive syndrome, which involves prolonged symptoms affecting cognition, memory, exertional tolerance, headache, sleep, mood and more. Post-concussive syndrome can last from weeks to years, so proper recovery is crucial. But most guidance on the best way to do this is based on consensus opinion, not evidence.
In 2012 in Zurich, the 4th International Conference on Concussion in Sport resulted in a consensus statement, which proposed an approach to diagnosing concussion, then an algorithm for the safe return to play which first involved cognitive and physical rest, then a staged return to full physical activity.
Although it has been a good starting place, there are critics of this approach. They suggest the approach to diagnosis lacks specificity, allowing those who may truly be concussed to underreport symptoms and return too soon, while certain subjective symptoms seen in the general population can be mistaken for symptoms due to concussion. This can lead to prolonged restriction of activity, with the potential for associated consequences such as deconditioning, stress and depression.
Since the Zurich statement, several studies have suggested there is a sweet spot between returning too soon or too late to regular cognitive and physical activities, with either extreme leading to increased risk of post-concussive syndrome. Fortunately, studies are underway to evaluate different options for a balanced, staged program to return to school with reasonable accommodations, even though some symptoms may persist. After a student can return to learn, they can then follow a staged return-to-play protocol.
It has been proposed that in 80 to 90 percent of individuals who sustain mild traumatic brain injuries (concussions), full symptom resolution occurs in seven to 10 days. The trick will be discovering the approach that allows sorting out the other 10 to 20 percent who take longer and are at risk for post-concussive syndrome.
Though the Zurich criteria may be considered by some to be overly conservative, we are in a much better place these days than when I was a kid, and "getting your bell rung" tackling somebody was evidence that you had a great tackle. Once you regained consciousness, you were applauded by your coach and teammates and told to "get back in there!"♦