From the AAP’s Clinical Report
Sport-Related Concussion in Children and Adolescents
Many athletes will report increased symptoms with cognitive activities after a concussion,
which makes intuitive sense because the concussion is a functional rather than structural
injury of the brain. Athletes with concussion often have difficulty attending school and
focusing on schoolwork, taking tests, and trying to keep up with assignments, especially in
math, science, and foreign-language classes. Reading, even for leisure, commonly worsens
To prevent exacerbation of the athlete's symptoms and allow for continued recovery,
"cognitive rest" is recommended. This rest may include a temporary leave of absence from
school, shortening of the athlete's school day, reduction of workloads in school, and
allowance of more time for the athlete to complete assignments or take tests. Taking
standardized tests while recovering from a concussion should be discouraged, because
lower-than-expected test scores may occur. Test scores obtained while the athlete is
recovering from concussion are likely not representative of true ability. Communication with
school nurses, administrators, and teachers to be sure they understand these
recommendations is imperative.
After reintegration into school, a student should be allowed adequate time to make up
assignments, and the overall volume of make-up work should be reduced. Because students
physically look well, it is not uncommon for teachers and other school officials to
underestimate the difficulties that a student is experiencing and may downplay the need for
cognitive rest. Education of teachers, counselors, and school administrators regarding the
cognitive effects that a concussion may have on a student is important.
Other activities that require concentration and attention, including playing video games,
using a computer, and viewing television, should also be discouraged, because they may
exacerbate symptoms. If phonophobia is a significant symptom, exposure to loud music or
the use of portable electronic music devices with head phones should be avoided.
Sunglasses may be considered for athletes with significant photophobia. Athletes often have
slowed reaction times after a concussion and may need to avoid driving temporarily.
After a concussion, all athletes should be withheld from physical exertion until they are
asymptomatic at rest. With the proposed energy crisis in the brain, increased energy
demand in the brain from physical activity may exacerbate symptoms and has the potential
to prolong recovery. An athlete in the acute phase of a concussion should be restricted
from physical activity.
Concussion Rehabilitation/Stepwise Return to Play
Each stage in concussion rehabilitation should last no less than 24 hours with a minimum of 5
days required to consider a full return to competition. If symptoms recur during the
rehabilitation program, the athlete should stop immediately. Once asymptomatic after at least
another 24 hours, the athlete should resume at the previous asymptomatic level and try to