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NFHS | www.nfhs.org/hstoday
Injured student-athletes need to use the concept of “small bites,”
meaning they can attempt small, short-duration activities and con-
tinue to perform them as long as they remain asymptomatic. If their
symptoms worsen, they need to take a step back and allow the symp-
toms to improve. If they do well, they can attempt a more challeng-
ing activity or a longer duration (a larger “bite”). This approach
continues until they are back to full academic activity.
In order to keep this progression moving forward, it is essential to
have the student-athlete closely monitored by the athletic trainer
and/or school nurse on a daily basis. Excellent communication must
be maintained between the treating physician, the athletic trainer,
school nurses, guidance counselors, teachers and parents.
There has been a quantum shift in the management of concus-
sions during the past decade. Physicians and neuropsychologists have
moved away from concussion grading scales and the “cookbook”
approach for return to play. In addition, athletes suspected of suffer-
ing a concussion are not allowed to return to play in the same con-
test and not allowed to return to the activity until they are cleared by
an appropriate health-care professional.
A graduated return-to-play program is now used to ensure the
athlete is asymptomatic at both rest and exertion prior to allowing
full activity. This same approach can be used in returning concussed
athletes to full academic activity because this is every bit as important
as the return-to-play decision. Too often, student-athletes try to return
to class, take tests/quizzes or work on assigned projects before their
brain has recovered from their injury. This only delays their healing
and their return to function.
Table 1 outlines possible guidelines for returning student-athletes
to full classroom and academic work. Depending on the severity of
the concussion and the type and amount of symptoms, the athletes
would be started at Academic Stage I, II or III. They are allowed to
progress to Stage IV as they can tolerate. Every day, they should be
re-evaluated by the school nurse and/or athletic trainer to check on
progress. Also during this time, they typically receive another neu-
rocognitive test to monitor their progress. Not until they advance to
Academic Stage IV do they return to any sports activity or start a re-
turn-to-play protocol.
These are only guidelines. Every school will need to approach con-
cussions and academic accommodations differently. In addition, every
concussion is different, so each one needs to be treated individually.
With regard to the concussed football player mentioned earlier, he
was able to attend limited class the following Monday. He started
classes later than usual, did not attend band class and he had to leave
physics class early because his symptoms got worse. Over the next
three days, he was able to progress to full class attendance, but re-
quired another week before his symptoms cleared enough to start
taking tests and quizzes.
Two weeks after his injury, he “passed” his neurocognitive and
balance tests and started the progression back to play. He was able
to play in the game the following Friday, and has been symptom-free
since. Over the next several weeks, he was able to catch up on the as-
signments and tests he missed while he was concussed. This approach
took all the pressure off him and allowed him to recover from his con-
cussion as quickly and safely as possible.
References
1. McGrath N. Supporting the student-athlete’s return to the classroom after a sport-related
concussion. J Athl Train. 2010;45(5):492-498.
2. Guskiewicz KM, et al. National Athletic Trainers’ Association Position Statement: Manage-
ment of sport-related concussion. J Athl Train. 2004; 39: 280-297.
3. Previously unpublished data from the National High School Sports-Related Injury Surveillance
Study (High School RIO) for 2005/06-2010/11. Annual summary reports available at http://injuryre
-
search.net/rioreports.aspx.
Dr. William M. Heinz practices sports medicine in Portland, Maine. He received his un-
dergraduate degree from Purdue (Indiana) University and then graduated from Indi-
ana University School of Medicine. He is the team physician for the Portland Sea Dogs
and a team physician for U.S. Soccer. He is also the company physician for the Port-
land Ballet and the orthopaedic consultant for the Portland Pirates, Bridgton Academy,
Gould Academy and Deering High School. Dr. Heinz is a member of the NFHS Sports
Medicine Advisory Committee.
Stage Goals/Key Ideas Expected Duration Teacher’s Actions Student’s Actions
I
II
III
IV
Complete rest.
Significant deficits
in processing and
concentration.
Cognitive activity
as tolerated.
Gradual increase of
time and energy,
slowly resuming full
workload.
Complete resumption
of normal activities.
2-6 days
2-14 days
Variable duration.
Hopefully 3-7 days,
possibly more.
• Out of school.
• Strict limits for use of computer, cell phone, texting, video games.
• No Physical/Sports Activity.
• In school as tolerated.
• When present, observing not participating. Get copies
of notes, handouts, etc.
• Communicate with teachers about progress/challenges.
• Be patient with slow recovery, just do your best.
• No Physical/Sports Activity.
• In class/school full-time.
• Communicate with teachers on your progress with assignments.
Communicate with teachers and parents on the pace of resuming
a full workload and competing make-up work.
• No Physical/Sports Activity (including gym class).
• Resume all normal activities.
• Progress with athletic trainer – supervision resumption
of participation in athletics.
• Contacted by school nurse.
• Explanation of injury and current plan of care.
Develop lists of three categories for all assignments:
1. Excused: Not to be made up.
2. Accountable: Responsible for content, not process. May be notes
or work shared by a classmate, or may be covered in
a review sheet.
3. Responsible: Must be completed by student and will be graded.
• Prioritize assignments with student, both make-up work
and new work.
• Continue to use lists with the three categories for assignments
until all work is completed, and assist with setting a timeline for
completion of assignments.
• Monitor completion of assignments.
• Communicate with parents and staff as to when student is caught
up with assignments and working at the same pace
as their classmates.
• Communicate with Guidance Office as grades are updated.