UMEM Educational Pearls

Category: Pediatrics

Title: Pediatric Concussions - submitted by Mike Santiago

Keywords: Concussion, sports injury, TBI, return to play (PubMed Search)

Posted: 9/30/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

You are seeing a high school football player following a head injury.  After your exam or head CT, you determine the child to have had a mild traumatic brain injury (aka concussion).  You are ready to discharge him home when the parents or coach ask you when he can return to playing football.

A concussion is a form of functional, rather than structural, brain injury that displays no evidence of injury on structural neuroimaging.   Symptoms include transient loss of consciousness, amnesia, vomiting, headache, poor school work, sleep changes, and emotional lability.  Remember that children’s brains (even adolescents) are still developing, and are more prone to prolonged recovery following injury.

Recovery of symptoms usually follows a sequential course.  Current guidelines recommend a stepwise return to play (aka concussion rehabilitation) involving both physical and cognitive rest (e.g. no texting, video games, limited school work).  Once asymptomatic, the patient goes through each stage with at least 24 hours between stages.  If symptoms return during a stage, then the patient is expected to return to the previous stage for 24 hours before attempting the higher stage again. 


Return to Play Guidelines:

Rehabilitation stage

Functional Exercise

  1. No activity

Complete physical and cognitive rest

  1.  Light aerobic activity

Walking, swimming, stationary cycling at 70% maximal heart rate, no resistance exercise

  1. Sport-specific exercise

Specific sport related drills but no head impact

  1. Noncontact training drills

More complex drills, may start light resistance training

  1. Full-contact practice

After medical clearance, participate in normal training

  1. Return to play

Normal game play



  1. Halstead ME, Walter KD, and The Council on Sports Medicine and Fitness.  Pediatrics. 2010;126:597-615.