Concussion / Mild Traumatic Brain Injury Return to Participation

Protocols

2014 First Coast Sports Injury Symposium Concussion Workshop

Jim Mackie, Med, ATC, LAT

International Consensus Statement

Identifies the need for a gradual RTP protocol that includes a stepwise progression and only progress to the next level when asymptomatic

at the current level.

No cookie cutter return to play for all

• Sports related concussions are heterogeneous (diverse in character or content) and require an individualized clinical approach. Collins, et all.

• "A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion" December 2013

Interdisciplinary team approach

Targeted treatment pathways based on an individual's specific clinical trajectory and leveraging the interdisciplinary team's expertise, it is important to follow a standardized return to play (RTP) exertion protocol.

 

Essential Relationships

• Knowing your kids, involving peers, coaches, parents teachers in the process

• Ask the following day, how did you feel during & after the exercise, How were you that evening? That next morning, today?

• Ask about their school, social and home activities?

Balance with a return to learn progression

• Light cognitive activity at home• 1-2 hours a day in 30 minute increments• Sustained moderate activity with 30-45 minute

increments for 3-4 hours• Progress the younger more gradually• School re-entry - as tolerated, no testing first

week back

Graded return to play protocol

• What does this mean and what’s involved? • What are you measuring and evaluating?• Are you just doing activity or with a purpose?• AT18 FHSAA Form• Cleared by MD / DO to begin a graded RTP

Six step process – AT181. No Activity - Recovery2. Light aerobic exercise3. Sport – specific exercise4. Non-contact training5. Full Contact practice6. Return to full activity

Step wise process

• Each step to be completed in a 24 hour window

• Any return of symptoms, stop immediately and wait 24 hours or until asymptomatic

• Begin at the previous level • Performed under supervision of athletic

trainer, coach with each step initialed and dated

Step 2 - Light Aerobic Exercise• Asymptomatic and cleared to begin• Walking, swimming, stationary bike (10 – 15

min.), HR<40 – 50% max. • No Impact work or no weight training• Flexibility encouraged• Balance – Single leg or heel to toe• Quiet room with no distractions• Objective: Increased Heart rate

Step 3 - Sport Specific Exercise• Bike or treadmill (20-30 min., THR 40-60%)• Dynamic stretching (walking lunges)• Non contact drills• Examples: Bags, ladder, cones, running, throwing,

directional & agility drills• Objective: Add dynamic exertion & sport specific

movement

Introducing Dynamic Exertion• Incorporate dynamic (lateral, head & sport

specific) plyometric based movements that could provoke underlying vestibular symptoms or dysfunction.

• Assessment necessary to see if they have any return of vestibular or other symptoms following dynamic movements that mimic the sport.

• Helps reduce recidivism and ensures a safer and more informed RTP.  If undetected could lead to making one more susceptible to additional injuries

Step 4 - Non-contact training• Increased aerobic exercise (THR 60-80%)• Complex (non-contact) drills / practice, balance &

reach or multi task, bosu ball• Examples: Progressive Weight training, bag,

ladder, cone drills, running, throwing, agility, plyometric, change of direction

• Practice skill patterns of position• Objective: Exercise, coordination & cognitive load

Sport specific position skill progressions

• 5 – 10 – 20 yard or longer bursts• Diagonals, stop / starts• Roll out, plant & cut, back peddle, etc.• Foot drills, change of direction• Head turns, swivels, rotations…

Step 5 - Full Contact Practice• Full contact Practice• Examples: Progressive intensity one on one, 7 on

7; blocking, locking up, tackling, controlled scrimmage (monitor number of reps)

• Full lifting, running & performance training• Objective: Restore confidence and simulate game

situations

As an athletic trainer or other healthcare provider your initial and on-going clinical interviews will assist the MD with their treatment plan.

Local Resources for RTP Help? • Identify the Schools

Athletic Trainer

• Local Rehab Centers that may offer supervised program

Physician Communication

• Office visit or not?• Depends upon physician (MD/DO)• Trust in person monitoring daily progress with

Athletic Trainer, Coach, Therapist, etc.

Step 6 -Return to full activity• Return to competition• Written documentation on file• Monitor & report any return of symptoms• Objective: After completion of each step

successfully, Form AT18 must be completed by MD / DO

Some considerations

• Most RTP models start at Stage 1 & spend at least 24 hours before progressing to the next stage.

• Definitely with the adolescent & younger athlete

• Assumes that concussion recovery trajectories are homogenous and linear in nature

Considerations & research shows

• Example: athlete presents symptom free and neuro-cognitive test scores at baseline levels only 2 days post injury may or may not need to begin at Stage 2 exertion. The athletic trainer or individual may progress them through several stages in day one without provocation of symptoms.

• However, symptoms alone may not be the best approach to assessing RTP following exertion.

Final Considerations• Researchers showed 1/3rd athletes who were

symptom free failed at least one neuro-cognitive test.

• Indicates the need for a post exertion test if you feel they are being less than honest with their symptom reporting.

• Regardless, all should complete a stepwise program of light aerobic exercise and progressing through sport-specific movements, light contact drills and final, full contact practice.

Thank You

Jim Mackie, Med, ATC, LATJacksonville Sports Medicine

Program