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
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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 – AT18
1.
2.
3.
4.
5.
6.
No Activity - Recovery
Light aerobic exercise
Sport – specific exercise
Non-contact training
Full Contact practice
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
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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
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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
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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 neurocognitive 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 sportspecific movements, light contact drills and final, full
contact practice.
Thank You
Jim Mackie, Med, ATC, LAT
Jacksonville Sports Medicine Program