My Child Has Concussion – Part 2

Having your child diagnosed with a concussion can certainly be a confronting thing. You may have heard the term ‘CONCUSSION’ being tossed around the media recently and, understandably, have concerns. The good news is they will have a full brain recovery if the concussion is managed well. Only with a full brain recovery will it be SAFE to return to sport. 

After your healthcare provider has diagnosed your child with concussion, they should explain to you the process of rehabilitation. We call this the ‘Gradual Return to Play’ (GRTP) protocol in which there are numerous stages to complete. These stages are divided into the ‘cognitive’ stream and the ‘exercise’ stream, which can be progressed through at different rates. Your child will need to complete each stage successfully, without increasing their symptoms before moving to the next stage in the stream. If their symptoms increase at any stage, they will need to revert back to the previous stage in the stream. Your child will also need to spend a minimum of 24 hours in each stage before moving to the next. On successful completion of the entire protocol, you will know that they are completely safe to return to any sport. Let’s break down each stage below!

THE ‘RETURN TO SCHOOL/WORK’ STREAM
STAGE 1: Setting the scene!

This stage is all about your child taking it a little bit easier than usual. After a concussion they may be feeling more fatigued, irritable, nauseous or have a headache. They may be feeling completely fine. Despite what they feel, the rule of thumb is they shouldn’t do anything which increases their symptoms. They are allowed to do light cognitive activity (reading) or light physical activity (gentle swimming). We certainly don’t want to push them in a dark room and sit in a corner doing absolutely nothing! Take it easy, don’t provoke symptoms and don’t do anything where their head is at risk of being hit.
This is also the stage for an appointment with a healthcare practitioner who has experience in concussion management. They will formally diagnose the concussion, rule out more serious issues, and provide some early treatment.Types of treatment that can be provided may include:

– Neck treatment, including manual therapy and exercises. 100% of concussions also have an associated neck whiplash injury.
– Vestibular exercises, if your child is showing any issues with dizziness.
– Expert education on the process of concussion and answering any questions.
– Writing ‘academic accommodations’ to teachers so everybody involved is on the same page of how much schoolwork is appropriate for your child.
– Temporary diet plan to reduce impact of inflammation upon the brain.

Once your child is able to complete 15-minute stints of cognitive tasks (on their phone or reading), they can progress to stage 2.

STAGE 2- Light Cognitive activity:

This stage is fairly straightforward! The goal is for your child to be able to tolerate 45 minutes of cognitive activity without an increase in symptoms. This could include 45 minutes of homework, being on their phone or reading a book. If they do feel an increase in symptoms – that’s ok! Get them to take a break and to try again a little bit later. They can progress to stage 3 if they can tolerate 45 continuous minutes of continuous cognitive activity. They also need to spend at least 24 hours in stage 2!

STAGE 3 – A half day of school!

This stage is usually looked at with anticipation from the parents and a rolling of the eyes from the kids. It is time to get your child back to school! For this stage, your child has already shown that they can tolerate 45 minutes of thinking activities, but this is definitely a step up. Similar to the previous stages, we don’t want any increase in symptoms from your child. If any symptoms increase, they will need to stop school and revert back to stage 2 for 24 hours. It’s useful to be strategic about introducing the half days of school and certain academic accommodation will be provided. Some academic accommodations that your healthcare provider may suggest include:

• Allowing periods of rest
• No tests
• No P.E. classes
• No recess or lunch (but a supervised learning break)

Having no P.E. or recess/lunch may seem harsh, but it is necessary. It is important to remember your child’s brain is still healing and a second knock may lead to a subsequent concussion, with potentially serious consequences. 

Even if your child is feeling 100% at lunchtime, after a half day of school, it is still important to remove them and not to push through. If after the 24-hour period there was no increase in symptoms then they will be allowed to progress to stage 4.

STAGE 4 – A full day of school!

Exactly the same idea and the same restrictions as stage 3; the only difference is your child is allowed to stay at school for the entire day. If they get through the day with no symptom provocation, then they are welcome to move to stage 5 in the next 24 hour period!

STAGE 5 – A Full day of school with no academic restrictions (still avoid P.E)

The ‘RETURN TO SPORT’ stream

STAGE 1 – Stage of transition!

Stage 1 of this stream is a milestone. It means your child is able to do a full day of school without and worsening of their condition. This is great news, and the brain is well on its way to recovery. Your child should have been doing some light physical exercise (walking, swimming) without any problems. During Stage 1 in this stream, your child will have to return to your healthcare provider and attempt the Buffalo Concussion Treadmill Test (BCTT). 

 What is the Buffalo Concussion Treadmill Test (BCTT)?

The BCTT is a walking test where your child will be put on a treadmill which gradually increases in its incline. The BCTT is a test which helps determine whether systems regulating blood flow to the brain have fully recovered, which can be impaired after a concussion. Within the test, their heart rate and their symptoms will be closely monitored to ensure they are safe at all times. To pass, they will need to reach a sufficiently high level of exertion without a sufficient increase in symptoms. Don’t worry, it’s just a walking test and they won’t need to run!

• If they pass:  They are allowed to progress to stage 2 and have all of their academic restrictions lifted (except no P.E.). This means they can go back to full time tests, homework, assignments- they will be pleased! 

• If they fail:  We will prescribe a sub-symptom heart rate intensity of which they are allowed to exercise with at home. For example, they may be prescribed a training heart rate intensity of 120 beats per minute. Gradually their bodies will adapt to this, get stronger and will retest the BCTT at another date. 

The BCTT has been shown to be completely safe and does not prolong symptoms. In fact, research shows that exercise is one of the best ways to recover from the symptoms of concussion! It is important to remember that passing the BCTT doesn’t mean your child is cleared to play. They will be allowed to move to stage 2 after spending at least 24 hours in stage 1. Trust us, they will be so excited to move up to stage 2 and beyond!

STAGE 2: The Bridge to Sport

By this stage we can imagine your child will be pretty keen to get back to sports in some capacity. Well, good news, this is the stage for them! After passing the BCTT they are allowed to lace up their boots and start some sport-specific activities. They still MUST NOT put themselves in a position where their head may be knocked (such as contact drills).

The drills that your child is cleared for in stage 2 includes:

• Running and easy agility
• Kicking/passing/shooting a soccer ball
• Passing and catching a rugby ball

If your child passes stage 2 without any increase in their symptoms, they can progress to stage 3.

STAGE 3: More complicated drills.

We are getting towards the finish line! Stage 3 means that the drills of stage 2 are a little bit more complicated. Your child is also allowed to restart any resistance or strength training. Again, they must not put themselves in a situation involving incidental contact or a head knock. Typical drills included in stage 3 are:

• Squats
• Dribbling around cones and shooting a soccer ball
• Non-contact team drills
• High-intensity agility drills

Your child will need to be completely symptom-free to complete stage 3 and progress onwards to stage 4.

STAGE 4: Getting clearance to return to contact!

Stage 4 is the ultimate stage for your child to attempt. It will involve a vigorous strength and aerobic exercise and a repeat of their baseline test (If they have one). This stage is a necessity as most sports with a high risk of concussion are vigorous and physical. If they can pass this test, it means that their concussion has fully recovered. You can be confident that their brain is not placed in undue risk from returning too early. 

The exercise test we use is called the Chicago Blackhawks Test. This test looks at your childs symptoms in response to vigorous physical exercise, strength and balance. Check out the video below!

If your child manages to pass the exercise segment of the test, then they will be asked to repeat their baseline test. A baseline test will look at the comparison to your child’s pre-injury level data, including memory, balance and visual tracking. Passing this baseline test after a physical exertion test is the gold standard in safely returning an athlete to contact sports.  If they have not done a baseline test a VOMS (vestibular-ocular motor screening) test will be given in its place. The VOMS test is a good test for clearance, but unfortunately not as good as the baseline re-test. 

Some sports will specifically require a doctor’s medical clearance which is important to also attain. The results from clearing the Blackhawks and Baseline test will ensure both you and your doctor that it is SAFE to return to contact sports. After being completely symptom-free, passing stage 4, returning to full time school, and being formally cleared, your child may progress to stage 5.

STAGE 5: Contact Training

Your child is fully cleared to participate in a full contact training session with their team. It may take them a bit of time to get back into the swing of things. They may get tired a little easier on their first session back but they should get their fitness back with time! 

STAGE 6: Full Return to Play

If your child was successful in their contact training session, with no symptoms, then onwards to stage 6! They are allowed to fully participate in all contact training sessions and games. They have safely returned to sport!

It was a long road but an important one. Athletes who are not managed properly, following a concussion, pose a 2.5x higher risk of secondary injury following returning to sport. These secondary injuries could include anything – concussion, ankle sprains etc. If they are managed well, then there is no increased risk of secondary injuries on returning to sport. Now all that is left to do is put your feet up, relax and watch your child score goals!

Sydney Concussion Centre provides expertise in the diagnosis and management of concussion. We will work with your child to promote their full recovery and strictly clear them only on FULL recovery of the brain.

Community Seminars for Sporting Clubs may be available in your area. Contact our Practice Manager for more information.