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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