Adolescent with Concussion and Return to Learn
A 15-year-old female soccer player sustains a head injury during a game after colliding with another player. She did not lose consciousness but had a headache and dizziness immediately. She was removed from play. On the sideline, the SCAT6 showed symptoms of headache, dizziness, and difficulty concentrating. She is now 3 days post-injury and still reports headache and fatigue. She is a straight-A student and wants to return to school full-time. Her parents are concerned about her falling behind. She has a history of migraine. She wants to know when she can play soccer again.
1. What is the recommended approach to return to school and return to sport?
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The athlete should follow a gradual return-to-learn protocol first. She may need academic accommodations such as reduced workload, rest breaks, extra time on tests, and a quiet environment. She should not return to full school days until she can tolerate cognitive activity without worsening symptoms. Once she is symptom-free at rest and with school, she can begin the return-to-sport protocol: 1) symptom-limited activity, 2) light aerobic exercise, 3) sport-specific exercise, 4) non-contact drills, 5) full-contact practice, 6) return to game. Each step should be at least 24 hours apart and only if asymptomatic. Given her history of migraine and persistent symptoms at day 3, she should be monitored closely. She should not return to soccer until she completes the protocol and is cleared by a healthcare provider.
2. What factors increase her risk for prolonged recovery, and how should they be managed?
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Risk factors for prolonged recovery include: history of migraine, female sex, adolescent age, and high symptom burden initially. These should be addressed with a multidisciplinary approach. She should avoid complete rest (which can prolong recovery) and instead engage in sub-symptom threshold aerobic exercise. Cognitive rest should be relative, not absolute. Treat her headache with appropriate medications (avoid overuse of NSAIDs). Sleep hygiene and nutrition are important. She should be evaluated by a sports medicine physician with concussion expertise. If symptoms persist beyond 4 weeks, consider referral to a concussion clinic for further management.