Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League-Big Ten Epidemiology of Concussion Study

Abstract

Objective: To examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC).

Methods: In a multisite prospective cohort study, we identified the frequency of initial 24-48 hours physical and cognitive rest, and the sequence of (1) symptom resolution and return to (2) exertion activity, (3) limited sport, (4) full sport and (5) full academics. In resulting profiles we estimated the likelihood of return to full sport ≤14 days or prolonged >28 days and tested for variability based on timing of the stages.

Results: Among 1715 athletes with SRC (31.6% females), 67.9% had 24-48 hours initial physical and cognitive rest. The median was 6 days to return to full academics, 8 days to symptom resolution and 9 days to exertion. Three profiles emerged; all had the same sport-specific return progression, but varied in the relative timing of full academics. In unadjusted analyses, full academics as the first stage corresponded to the longest time to return to full sport, and initiating exertion the same day as symptom resolution resulted in the shortest time. In adjusted regression analyses, athletes initiating full academics while still symptomatic were 21.5% less likely (95% CI -27.4% to -15.5%) to return to full sport ≤14 days and, analogously, 19.1% more likely (95% CI 13.4% to 24.7%) to have prolonged return >28 days. While additionally controlling for initial rest, sex, symptom count and concussion history, the likelihood of prolonged return >28 days was 37.0% (95% CI 25.2% to 48.8%) in athletes initiating exertion considerably before symptoms resolved (ie, 7+ days), but only 3.6% (95% CI -1.4% to 8.6%) in athletes initiating exertion shortly before achieving symptom resolution (ie, 3-4 days).

Conclusion: We found evidence that sequential progressions were consistent with current recommendations including brief initial rest, and the initiation and relative timing of each stage impacted the final return-to-sport outcome.

Keywords: Cohort Studies; Sporting injuries; Sports.

Figure 1

Three recovery profiles defined the sequence in which athletes reached stages relevant to return-to-activity stages after sport-related concussion. Profiles varied in timing of return to full academics, yet all adhered to sport-specific Consensus in Sport Group guidelines.

Figure 2

Unadjusted Kaplan-Meier curves displaying the median time to return to full sport after sport-related concussion was longest in Profile 3 (14 days), in which athletes initiated full academics first relative to other stages, compared with Profiles 1 and 2 (p<0.001).

Figure 3

Scatterplots showing the number of athletes with sport-related concussion by the timing of symptom resolution post-injury relative to the timing of return to activity stage. (A) Half (51.9%) returned to full academics before symptom resolution, whereas (B) 66.0% returned to exertion, (C) 92.1% returned to limited sport and (D) 97.0% returned to full sport after symptom resolution.

Figure 4

Unadjusted Kaplan-Meier curves showing the median time to return to full sport among athletes with sport-related concussion was longest if they (A) started exertion activities before symptoms resolved (p<0.001) or (B) returned to full academics before symptoms resolved (p<0.001).

Figure 5

The predicted likelihood of returning to full sport ≤14 days (A) was progressively lower with more days elapsing between initiating exertion activities after symptom resolution occurred. Additionally, the likelihood of returning to full sport ≤14 days was systematically lower in athletes that (B) had initial 24–48 hours rest and (C) initiated academics 4+ days before symptom resolution. The predicted likelihood of returning to full sport >28 days (D) was progressively higher with more days elapsing between initiating exertion activities after symptom resolution occurred. Additionally, the likelihood of returning to full sport >28 days was systematically higher in athletes that (E) had initial 24–48 hours rest and (F) initiated academics 4+ days before symptom resolution.