Concussion Recovery Timeline of High School Athletes Using A Stepwise Return-to-Play Protocol: Age and Sex Effects

Abstract

Context Implementation of a stepwise return-to-play (RTP) protocol has become the standard management strategy for high school athletes to ensure a safe RTP after concussion. The detailed characteristics of the recovery timeline throughout the steps of an RTP protocol have not been delineated among the adolescent population. Objective To investigate the days spent in each step of the stepwise RTP protocol in an adolescent population and examine the effects of age and sex on recovery time. Design Cross-sectional study. Setting Local schools. Patients or Other Participants Student-athletes from 57 schools. Intervention(s) A total of 726 patients with concussion (age = 15.5 ± 1.2 years, males = 454, females = 272) were included. The 7-step RTP protocol consists of the following steps: (1) complete cognitive rest, (2) full return to school, (3) light exercise, (4) running progression, (5) noncontact training drills and weight training, (6) full-contact practice or training, and (7) return to game play. The data were obtained by certified athletic trainers as a part of the statewide standardized concussion-management protocol. Main Outcome Measure(s) Days spent in steps 0 to 6 as well as a breakdown of days by sex and age. Results The average total RTP days were 20.2 ± 13.9. Half of this time was spent in the return-to-school phase (steps 2–3: 10.2 ± 10.0 days). Compared with 17-year-old participants, younger participants (age = 14–16 years) took 3 or 4 days longer to start step 3 and to reach step 6 (P < .05). Females took longer to reach step 6 than males (21.6 ± 15.5 versus 19.3 ± 12.7 days) because they took longer to reach step 3 (14.7 ± 11.4 days) than males (13.0 ± 10.0 days; P < .05). Conclusions Our study provides an estimated stepwise concussion recovery timeline for adolescent student-athletes. Clearance to start step 3 was the benchmark for the recovery timeline, as the duration of the exercise portion of the protocol was consistent across the age and sex groups.

An epidemiologic comparison of acute and overuse injuries in high school sports

“…These observed differences are most likely a result of the nature of these types of injury; while overuse injuries are the result of repetitive microtrauma with inadequate rest time for repair, acute injuries can result from greater forces resulting in injuries that may require longer healing time (Roos et al 2014 ; DiFiori et al 2014 ; Hubbard et al 2008 ; Karladani et al 2001 ). These results may also be due to the number of concussive injuries which often require > 1 week of recovery time when following return-to-play protocols (Tamura et al 2020 ). Although time loss due to some injuries may be inevitable, the development of training/competition schedules with adequate rest time built in and continued improvement of treatment protocols may lead to quicker return-to-play and reduce the number medical disqualifications for both acute and overuse injuries.…”

Time-to-Event Analyses: Return to Unrestricted Participation Following Sport-Related Concussion in a Cohort of High School Athletes

“…12 Additionally, Tamura et al also demonstrated longer post-concussion recovery in a study of Hawaii high schools from 2010-2014 which resulted with an average time-loss from activity of approximately 20 days for 726 student-athletes. 15 The results of these studies 12,15 show the true heterogeneity of SRC recovery, but a reassessment of these outcomes is needed as data were collected prior to the release of the most current consensus and position statements and their accompanying updated concussion management recommendations.…”

“…Analysis by grade in school yielded a significant log-rank test (χ² (3) = 8.21,p = .014) for median days to unrestricted RTP. However, clinical significance by grade was not meaningful as the median and interquartile ranges were similar between grades (9 th : 11[6][7][8][9][10][11][12][13][14][15][16] days, 10 th : 11[6][7][8][9][10][11][12][13][14][15][16] days, 11 th : 11[6][7][8][9][10][11][12][13][14][15][16] days, 12 th : 11[6][7][8][9][10][11][12][13][14][15][16] days). There was no difference between levels of competition (e.g., freshman, JV, varsity) (χ² (2) = 4.02, p = .134).…”

Time-to-Event Analyses: Return to Unrestricted Participation After Sport-Related Concussion in a Cohort of High School Athletes

“…12 Specifically, boys' baseball, basketball, and soccer had the highest percentages of athletes returning to play within 6 days of injury, and girls' lacrosse, softball, and tennis had the highest percentages of athletes returning to play at .28 days. 12 Additionally, Tamura et al 15 demonstrated longer postconcussion recovery in a study of 726 Hawaiian high school student-athletes from 2010 to 2014; the average time lost from activity was approximately 20 days. These results 12,15 showed the true heterogeneity of SRC recovery, but a reassessment of these outcomes is needed as the data were collected before the most current consensus and position statements and their accompanying updated concussion-management recommendations were released.…”