Return To Play Protocol
A player with a suspected concussion has to be examined by a qualified medical doctor. This doctor should be experienced in the handling of concussions. They will place the athlete on a ‘return to play’ path, listing the steps that the athlete is to use for healing their brain. In most cases, this is deemed to be a ‘return to play protocol‘. It is important to note that this may differ with each person.
An athlete that was diagnosed with a concussion typically has to migrate through a ‘Return To Play’ (RTP) scenario. This procedure will differ in each organization. There are no set number of days for return to play to occur. 3-4 days, to 7-10 days have been generally indicated, but the reality is that the situation is determined by the signs & symptoms that each individual may have, which vary widely. Items such as shown in the box above are eliminated, or severely curtailed.
In a return to play program, there are two items that are focused on:
- Physical Activities
- Cognitive Activities
Physical Activities And Return To Play
No physical activity is typically allowed while signs & symptoms are evident. After these have subsided, a graduated return to physical play may be implemented, in stages. The player is monitored at each stage, to see if any signs/symptoms return. Progression to the next stage occurs if all is well, after completing the current stage. An example of stages may be as follows.
- No physical activity
- Light physical activity (walking, swimming, stationary bike…. No resistance training).
- Sport specific exercise. Warm up, non-strenuous exercises
- Non-contact training drills
- Full-contact training activities–no game play
- Normal game play
Cognitive Rest
Cognitive (mental) rest is required for the brain to
heal properly. The American Academy of Pediatrics strongly recommends a rest period of near full mental (cognitive) rest in the first 3-5 days after an injury. The return to full cognitive activities is approached in stages, as like that of returning to physical activities.
An example of a cognitive program may be as follows:
- No school
- Half-day attendance with academic accommodations (students may need rest periods). Concentration being on ‘in school’ learning, with student resting fully at home. Tests should not be taken.
- Full-day attendance with academic accommodations. Gradual increase in homework. Limit to one test per day.
- Full-day attendance with no academic accommodations. Stress levels are to be kept low. Introduction of plan to recover any academic ground lost, in a gradual manner.
- Full school and school activity involvement.
To cognitively rest the brain may mean the following has to occur:
- Time off from school/work
- No school work
- No reading
- No visual activities that may stimulate the brain (i.e. video games, limited to no television, movies, texting, cell phone usage, etc.)
- No trip, socialization, at, or away from home
- Increased rest and sleep.
- No exercise/physical activities that results in perspiration/exertion.
Teachers should be involved in a graduated return to full cognitive functioning. All of the athletes teachers should be aware that the athlete is going through a concussion protocol. Academic accommodations should be sought, to help the athlete cope with the return to full classroom capabilities.
Academic accommodations could be items, such as follows:
- Reduced assignments
- Extra time to complete work/tests
- Rest periods during day
- Directions given in oral and written format
- Clear expectations discussed with student
- Large tasks broken into smaller components
In the return to play procedure, for physical and cognitive evaluation, this typically covers a 24 hr. time period. If the athlete is symptom free from concussion, they proceed to the next step. If issues arise, they do not proceed to the next level. Parents have to be actively aware of how their child is doing in each stage of the return to play program.
What Are Cognitive Abilities
Why The Brain Needs To Rest
When a brain is injured, cells leak potassium and absorb calcium. The absorbed calcium causes the mitochondria within the cell to not function properly. The mitochondria produces energy for the cell to operate. With the mitochondria not functioning properly, the cell does not receive the total energy required to function. The energy loss from the cells can be externally demonstrated by the victim showing concussion symptoms of headaches, nausea, or dizzy spells, due to the dysfunction of the cells. If the cell absorbs too much calcium, it will die, which leads to loss of brain functionality.
To heal the brain, the cells must generate the energy to repair the cells. Since the cells are in a weakened state, cognitive rest, where the brain is not using energy focused on an activity, helps to direct energy toward repair of cells. This focus tends to help cells heal faster. Energy that is otherwise used to focus on any particular cognitive activity will cause cells to take longer to heal properly, due to the lack of energy.
While the cells are healing, the injured cells are very vulnerable to a second injury, which can then destroy the cell. Second Impact Syndrome (SIS), could result from this. This is why it is imperative that a player that has received a concussion be immediately removed from play.
Example Protocols
Concussion return to activity plan
Return to play guidelines – ATSU
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