Sport-related concussions have garnered increased attention in recent years due to their potential short- and long-term consequences. The return to play (RTP) protocol is a critical component of managing concussions among athletes. In this article, we will delve into the recent recommended changes to the sport concussion return to play protocol, outlining the stages, considerations, and importance of ensuring a safe and gradual return for athletes.

Understanding the Return to Play Protocol:

The Return to Play protocol is a structured and gradual process that guides athletes through a series of steps to safely reintegrate them into their sport after sustaining a concussion. The primary goal of the protocol is to prevent premature return to physical activity that could put the athlete at risk for further injury and hinder their overall recovery. It is also common to have autonomic dysfunction or exertion intolerance when recovering from a concussion. This would cause an increase in an athlete's symptoms when they elevate their heart rate. This is the reason it is important to have a gradual progression of exercise intensity and maintain symptom free for 24 hours after each stage of the RTP before progressing to the next stage regardless of if you are returning to a contact sport or not.

Stages of the Return to Play Protocol:

There has recently been a recommended change to the sport concussion RTP that came from the 6th International conference on concussion in sport that was recently held in Amsterdam in 2022. These changes were made due to emerging evidence since the last consensus statement which was held in Berlin in 2016. These changes were made as they were found to be safe and effective in accelerating an athlete's recovery from concussion.

Old Sport Concussion RTP:

You may continue to see the “Old sport Concussion RTP” continue to be used as each organization will need to go through a process to update the RTP that they use. For High Schools the regulating organization is the State High School Leagues, College is NCAA, and professional organizations such as the NFL, and NBA regulate themselves. These changes will take some time unfortunately. But most original concussion protocols have these 6 main stages in common.

Step 1: Rest and Symptom Resolution:

- The athlete is advised to rest both physically and cognitively until all concussion symptoms have completely resolved.

- No physical activity, including sports-specific exercises, is allowed during this stage.

Step 2: Light Aerobic Activity:

- After symptom resolution, the athlete can engage in light aerobic activities, such as walking or stationary cycling, under the guidance of a healthcare professional.

Step 3: Sport-Specific Exercise:

- The athlete can participate in more sport-specific exercises that do not involve head impact or risk of re-injury.

- These exercises gradually progress from low-intensity to higher-intensity activities.

Step 4: Non-Contact Training:

- The athlete can engage in non-contact training drills, gradually increasing the complexity and intensity.

- These drills include coordination, balance, and agility exercises relevant to their sport.

Step 5: Full Contact Practice:

- In this stage, the athlete can participate in full-contact practices under the supervision of a coach and medical staff.

- Progression to this stage requires clearance from a healthcare professional.

Step 6: Return to Play:

- Once the athlete completes all stages and is symptom-free during exertion, they can be considered for full competition.

- Medical clearance is crucial before the athlete returns to competitive play. Click here for the 5th international consensus statement in sport.

Updated Sport Concussion RTP:

The main changes to the updated sport concussion RTP are that athletes are allowed to perform more physical activity in the initial stages of the RTP. They now do not need to be fully symptom free at rest before initiating light physical activity. Also, in stage 2 athletes are now allowed to perform light resistance training and are allowed to experience a mild and brief exacerbation of their symptoms which is new compared to the old RTP. A mild exacerbation of symptoms is described as no more than a 2-point increase of symptoms on a 0–10-point scale for less than 1 hour when compared to their baseline or pre-exercise symptoms. It has been found that early increased physical activity that does not cause a significant or lasting increase in an athlete's symptoms promotes a faster recovery from concussion. Click here for the first RCT article on aerobic exercise and concussion. Before progressing to the second half of the protocol all athletes need to be fully symptom free and rest and with exertion. Click here for the 6th international consensus statement in sport.

Free Access to 35+ Sport Specific RTP, all updated to the new recommendations. Download your copy here

Key Considerations and Factors:

1. Individualized Approach: The RTP protocol should be tailored to each athlete's specific needs, considering factors such as age, sport, severity of concussion, medical history, and response to treatment.

2. Medical Clearance: Throughout the protocol, medical professionals play a vital role in assessing the athlete's progress and determining when they are ready to progress to the next stage.

3. Symptom Monitoring: Athletes should be closely monitored for any return or exacerbation of concussion symptoms during each stage. If symptoms reoccur, progression should be paused, and consultation with a healthcare provider is necessary.

4. Cognitive Load: The athlete's cognitive function is considered alongside physical activity. If cognitive symptoms worsen during an activity, it may indicate the need to modify or halt the activity.

5. Gradual Progression: Each stage builds upon the previous one, ensuring the athlete's gradual exposure to increased physical and cognitive demands.

Communication: Open and clear communication between athletes, coaches, athletic trainers, and healthcare providers is crucial for effective implementation of the RTP protocol.

6. Communication: Open and clear communication between athletes, coaches, athletic trainers, and healthcare providers is crucial for effective implementation of the RTP protocol.

Importance of the Return to Play Protocol:

The RTP protocol is designed to prioritize athletes' safety and well-being. Following this protocol is vital for several reasons:

1. Preventing Re-Injury: Rushing back into play before full recovery increases the risk of a second concussion or more likely an exacerbation of their current concussion. This can have severe consequences and potentially lead to prolonged recovery.

2. Brain Health: A gradual return allows the brain to heal and adapt to increasing levels of activity, reducing the risk of long-term cognitive deficits.

3. Avoiding Post-Concussion Syndrome: Gradual progression and objectively making sure the athlete passes all concussion testing and not just saying they are symptom free improves the likelihood that they are 100% recovered prior to returning them to full activity. By doing all you can to ensure each athlete is fully recovered before they return to full participation minimizes the likelihood of post-concussion syndrome, a condition characterized by persistent symptoms long after the initial injury.

4. Educational Opportunity: The RTP protocol educates athletes, coaches, and parents about the importance of concussion management and safe return to play.

Remember, the athlete's health should always take precedence over competition, and any deviation from the protocol should be carefully evaluated by healthcare professionals.

Final Thoughts:

The sport concussion return to play protocol is a crucial component of ensuring athlete safety and well-being following a concussion. Adhering to the protocol's stages, seeking medical guidance, and maintaining open communication among all stakeholders are essential for a successful and safe return to competitive sports. Remember, the athlete's health should always take precedence over competition, and any deviation from the protocol should be carefully evaluated by healthcare professionals.

References:

Navigating the Recent Sport Concussion Return to Play Protocol Changes: Steps to Accelerate Safe Athlete Recovery