During cheerleading practice in April, Jana Duey’s sixth grade daughter, Karter, sustained a concussion when she fell several feet headfirst onto a gym floor mat. Days after, Karter still had a headache, dizziness, and sensitivity to light and noise.

Karter rested for a week and a half at home in Centennial, Colorado, then returned to school when her concussion symptoms were tolerable — initially for just half-days and with accommodations allowing her to do schoolwork on paper instead of a screen and take extra time to get to and from classes. Karter went to the nurse’s office when she had a headache, Duey said. She began physical therapy to rehab her neck and regain her balance after the accident left her unsteady on her feet.

After children get concussions, a top concern for them and their parents or caregivers is when they can go back to sports, said Julie Wilson, Karter’s doctor and a co-director of the Concussion Program at Children’s Hospital Colorado in Aurora. Returning to school as quickly as possible, with appropriate support, and getting light exercise that doesn’t pose a head injury risk are important first steps in concussion recovery, and in line with the latest research.

“It’s really important to get children and teens back to their usual daily activities as soon as possible, and as soon as they can tolerate them,” Wilson said.

In August, the Colorado Department of Education updated guidelines dispelling common myths about concussions, such as a loss of consciousness being necessary for a concussion diagnosis. The revised guidelines reflect evidence-based best practices on how returning to school and exercise can improve recovery. Educating families and schools about the new guidelines is critical, according to medical experts, particularly during autumn’s uptick in concussions from sports such as football and soccer.

More than 2 million children nationwide had been diagnosed at some point with a concussion or brain injury, according to the 2022 National Health Interview Survey. A flurry of studies in the past decade have shown that adolescents recover more quickly from concussions and decrease the risk for prolonged symptoms by exercising lightly, for example on a stationary bike or with a brisk walk, two days after a concussion. That time frame may also be the sweet spot for getting back to the classroom, as long as the kids can tolerate any remaining concussion symptoms.

“Even though the brain is not a muscle, it acts like one and has a use-it-or-lose-it phenomenon,” said Christina Master, a pediatrician and sports medicine and brain injury specialist at Children’s Hospital of Philadelphia.

Instead of waiting at home to fully recover, Master said, students should return to school with extra support from teachers and breaks in their schedule to relieve symptoms such as headaches or fatigue, with a goal of gradually doing more.

Every state has return-to-play laws for student-athletes that include policies such as removal from sports, medical clearance to return, and education about concussions. While some states, such as Virginia and Illinois, have “return-to-learn” policies, Colorado is not among them. It and 15 other states have community-based concussion management protocols.

That is what Colorado updated this summer. REAP — which stands for Remove/Reduce; Educate; Adjust/Accommodate; and Pace — is a protocol for families, health care providers, and schools to help students recover during the first four weeks after a concussion. For example, school personnel can use an email-based system to alert teachers that a student sustained a concussion, then send weekly updates with details about how to manage symptoms, like difficulty concentrating.

“We have new protocols to support these kiddos,” said Toni Grishman, senior brain injury consultant at the Colorado Department of Education. “They might still have symptoms of concussion, but we can support them.”

Symptoms of concussion resolve in most patients in the first month. However, patients with ongoing symptoms, called persistent post-concussive symptoms, can benefit from a multidisciplinary care team that may include physicians, physical therapists, psychologists, and additional school support, Wilson said.

David Howell, director of the Colorado Concussion Research Laboratory at the University of Colorado Anschutz Medical Campus, is studying how children and their families cope with the physical, cognitive, social, and emotional impacts of concussions. In some studies, adolescents wear sensors to measure exercise intensity and volume, as well as common symptoms of concussion, like sleep and balance problems. In others, children and their parents answer questions about their perceptions and expectations of the recovery process.

“What you bring to an injury is oftentimes exacerbated by the injury,” Howell said, citing anxiety, depression, or just going through a difficult time socially. Recovery can be influenced by peer and family relationships.

Duey said the most difficult part of Karter’s recovery was her not being able to participate in cheer for nine weeks, including her team’s final competition in Florida. Karter, now 12, watched practice and supported her teammates in the spring, but missing out tore her up inside, Duey said.

“There were a lot of tears,” Duey said.

While recognizing a concussion and acting quickly can help anyone, in practice, more than half of students in Colorado may slip through the cracks with undiagnosed concussions, according to Grishman’s estimates.

The reasons for missed diagnoses are many, Grishman said, including lack of education, barriers to medical care, parental reluctance to inform schools about a concussion for fear their child will be excluded from activities, or not taking symptoms seriously in a student with a history of behavioral issues.

Getting schools to follow concussion guidelines, in general, is a challenge, Grishman said, adding that some districts still do not. She said it was hard to track the number of schools that followed Colorado education department guidelines last year but hopes improved data collection will provide more specifics this year. During the past school year, Grishman and her colleagues trained 280 school personnel in concussion management across 50 school districts in Colorado.

Whenever possible, athletic trainers should be on the sidelines to support student-athletes, Master said, and athletes should be aware of concussion symptoms in themselves and their teammates and seek care right away.

But concussions are not limited to the school athletic field or sports like football or soccer. Adventure sports like parkour, slacklining, motocross, rodeo, skiing, and snowboarding also pose concussion risks, Wilson and Grishman said. “Cheerleading is actually one that has a lot of concussions associated with it,” Howell added.

Duey said Karter occasionally has headaches, but her balance returned with help from physical therapy and she no longer experiences symptoms of her concussion. She is back to flying with her cheerleading squad and preparing to compete.