Return to play
Joseph E. Herrera, DO, FABPMR, FACSM
Director of Sports Medicine
Interventional Spine and Sports Medicine
Department of Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
DISCLOSURE
No Conflicts of Interest
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Parent
Coach
Athlete
Avid Sports Fan
Sports Physician
Goals
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Understand the evolution of the return to
play criteria for concussion
Be aware of the current return to play
algorithm for concussion
Gain an understanding of the challenges
with return to play decision making
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Return To Play
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Why do we care?
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Repetitive head trauma
– Contact sports
– Physical abuse
– Epileptic seizures
– Head banging
Slowed recovery, cognitive impairment,
Behavioral dysregulation, mood disorders,
Neurodegeneration
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Gavett et al 2011, McKee et al 2009
In The Classroom
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An additive association between multiple episodes of
concussion and learning disabilities has been
demonstrated
Collins MW, Grindel SH, Lovell MR, Dede DE, Moser DJ, Phalin BR, Nogle S, Wasik M, Cordry D, Daugherty MK, Sears SF,
Nicolette G, Indelicato P, McKeag DB: Relationship between concussion and neuropsychological performance in college
football players. JAMA 282:964-970, 1999].
DECISION MAKERS
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Who says its OK to go back to play?
– Athlete
– Parents
– Coach
– Agent
– ATC
– Physician
Return To Play
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“Doc
I’m OK,
I don’’t want to let the team down”
When do you say OK…………
Return To Play
1. Chart
IT’S THE LAW
Concussion Management and Awareness Act (July 1, 2012)
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During school athletic activities schools are required to remove from activity
any student suspected of sustaining a mild traumatic injury (“concussion”)
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Student is not permitted to return to athletic activity until:
• Symptom free for more than 24 hours
• Evaluated by and received written signed authorization from a
licensed physician
• Schools required to follow any guidance from the student’s treating
physician in regards to limitations on school attendance and activities
Sports concussion
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Rest
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Expect gradual resolution in 7-10 days
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Start graded exercise rehabilitation when asymptomatic
at rest and post-exercise challenge
Sports concussion
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How long asymptomatic before exercise?
– If rapid and full recovery, then 24-48 hours
– One approach is to require that they remain
asymptomatic (before starting exertion) for the same
amount of time as it took for them to become
asymptomatic.
Management
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CORNERSTONE =
rest until
asymptomatic
 Rest from activity
 No training, playing, exercise,
weights
 Beware of exertion with
activities of daily living
 Cognitive rest
 No television, extensive
reading, video games
Return to Play
Rehabilitation stage
Functional exercise at each stage of
rehabilitation
Objective of each stage
1. No activity
Complete physical and cognitive rest.
Recovery
2.Light aerobic exercise
Walking, swimming or stationary cycling keeping
intensity < 70% MPHR
No resistance training.
Increase HR
3.Sport-specific exercise
Skating drills in ice hockey, running drills in
soccer. No head impact activities.
Add movement
4.Non-contact training drills
Progression to more complex training drills e,g.
passing drills in football and ice hockey.
May start progressive resistance training)
Exercise, coordination, and
cognitive load
5.Full contact practice
Following medical clearance participate in
normal training activities
Restore confidence and assess
functional skills by coaching staff
6.Return to play
Normal game play
• 24 hours per step
• If there is recurrence of symptoms at any stage, return to previous step
Return To Learn
As symptoms improve, a return to learn plan can include
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Shorter school days
Rest periods
Extended time for tests/homework/class work
Peer note takers
Audiotapes of class
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Persistant Symptoms
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What happens if symptoms persist?
– Do not return to play
– Avoid cognitive stressors such as the videogames,
TV, etc.
– Adjust the learners classroom environement
– Refer for neuropsychological testing
Goals
1.
2.
3.
Understand the evolution of the return to
play criteria for concussion
Be aware of the current return to play
algorithm for concussion
Gain an understanding of the challenges
with return to play decision making
THANK YOU
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Any Questions?
Joseph E. Herrera, DO, FAAPMR, FACSM
Director of Sports Medicine
Interventional Spine And
Sports Medicine Division
Department of Rehabilitation Medicine
5 East 98th Street, Box 1240B
New York, NY 10029