WESTBOROUGH, MA April 15, 2017 On March 15th across New England and most of the country high school spring sports take to the fields. Well actually most of the lacrosse and softball teams start out in school gyms or field house. Many actually rent out indoor playing fields to put in the hours needed to begin a rigorous new season. The starting dates are closely watched by members of the Massachusetts Interscholastic Athletic Association – MIAA. It is the same thing with football and fall sports – August 20th the ritual first day of Fall sports practice. In spite of these rituals and scores of other idiosyncrasies that teams share, concussion should not be an expected rite of passage for contact sports. Yet some people are still not taking it seriously.
“The protocol about which I write comes in sequence to the athlete being symptom free. When this happens he or she may begin a return to play protocol that consists of systematic activities designed to slowly stress the athlete in an effort to be certain that no symptoms will return as the athlete exerts himself over a 5-step sequence that ends in a full contact practice.”
I posted a short blog in January 2017 about the role of a stepwise return to play protocol. Most schools expect this protocol and are often surprised when the parent of an injured student marches in with a note authorizing return to full participation by the pediatrician – as if this trumps anything the CDC has implemented as the standard of care. This may now be the standard of care but is not being followed. In the past month I have been asked to write return to play protocols for athletes who had already been cleared to play by their pediatrician. You cannot have it both ways – either a player is held out until he is fully healed or he is at risk of prolonged debility and postconcussion syndrome if injured again during recovery. When it comes to middle or high school students the greater risk is missing days or weeks of school.
Case study – 2017
Just recently I saw a 12-year old middle school boy who had sustained a moderate injury while snowboarding. He had 2-3 weeks of significant symptoms including sensitivity to light and sound, headaches, irritability and changes in sleep pattern. He had taken one week off from school and returned 1-2 hours daily until fully reintegrated with his classmates. By outward appearances he was doing all the right things and had returned to his travel soccer team. Yet he was still having symptoms and should have taken a more focused approach to exerting himself. His school was beginning to push him to complete missing assignments that was adding to his anxiety and irritability. The child had been seen at a local concussion clinic who had cleared him for step 1 of the 5-step protocol. They prescribed the CDC 5 step protocol I have mentioned here but there was no in-school trainer to manage each step. This frequently falls on coaches or the school nurse. But by allowing him to exert himself and practice with his teammates he missed out of steps 2 and 3. His brain had not fully healed and was struggling to keep up with energy demand of school, homework, make-up tests and soccer. Concussion is an energy crisis resulting in less efficient processing and it was clear to me that he had not fully recovered from his moderate injury. He needed to start over and his parents heard this to be a set-back. They were protective of his emotional well-being and wanted him to be with his class and team mates. These are important considerations and must be figured into the recovery equation.
“There should be an understanding that no student may be expected to take tests – even state mandated achievement tests until they are fully recovered from their injuries. The failure to allow full recovery to take place prior to exerting the athlete places him or herself at risk for additional injury from second impact. Some students require a formal 504 support plan for the duration of their symptoms.” Sefton, 2014
In another case from spring soccer that I previously illustrated, a young high school boy was recovering and had still been having headaches. Their question was: could he travel to Portugal and play against an elite high school? They had been planning the trip for nearly a year. His anxiety over missing the trip was palpable but the risk of playing against older and more developed athletes was against my advice. He could attend the trip but not play. I am unsure what they decided to do but I did not see them again. For readers of this post I ask: Does it make sense to have an athlete who is still recovering to play at the elite level where competition is fierce and risk of injury is real? The 5-step protocol should not begin until the athlete is symptom free. Some believe the athlete should be symptom free for one week prior to beginning the return to play protocol. To see the CDC protocol click here.
Sefton, M (2017) Understanding Concussion: People are still not getting it. https://concussionassessment.wordpress.com/2017/01/29/understanding-concussion-people-are-still-not-getting-it/ Blog post taken April 2, 2017
Sefton, M. (2014) Prolonged symptoms signal delayed healing. Blog post: https://wordpress.com/post/concussionassessment.wordpress.com/643 Taken April 2, 2017