Concussion Management Best Practices: Stepwise Return to Play

We have discussed concepts of concussion management best practices, including early recognition and intervention as well as post-concussion management procedures.  Now, let's tie it all together.  How do we safely return an athlete to participation after he or she has sustained a concussion?  The answer:  implement a stepwise return-to-play process.  This stepwise progression begins where post-concussion management culminates; with an asymptomatic return to pre-injury baseline measures.  A stepwise return-to-play approach is also particularly useful in the absence of objective baseline and/or post-injury measures as it inherently protects the athlete from undiscovered deficits that may not arise until the athlete experiences the multitude of stimuli associated with his or her return to sport.  Furthermore, implementing a stepwise return-to-play progression is free and requires no additional technology or outside resources; so cost and access to technologies are not barriers and thus, a stepwise return-to-play progression can be implemented in any organization, in any setting.  Below is an industry-standard stepwise return-to-play progression.

Step 1: 24 Hours Asymptomatic

Step 2: Light Aerobic Exercise

Step 3: Sport-Specific Training

Step 4: Non-Contact drills/practice

Step 5: Full-Contact drills/practice

Step 6: Game Play/Return to Full Participation

              It should be noted that there is room for adaptability per sport within this process and stepwise progression.  Big picture: progress carefully along the control-chaos continuum, starting with high control and very low risk, moving to less control and more risk (chaos) as you mimic game-like activity.  The goal is for the athlete to remain asymptomatic throughout the process.  If symptoms arise, the athlete should wait until he/she is asymptomatic for 24 hours and resume the process at the previous step.  If the athlete remains asymptomatic, he or she may progress to the next step.  NOTE:  while there is room for some interpretation, I suggest completing no more than 1 step per day in the interest of the safety and well-being of the athlete.  I recommend obtaining a pre- and post-activity subjective symptom score to ensure the athlete remains asymptomatic throughout the entire process.  Remember:  "when in doubt, sit 'em out!"

-Greg Shedd, MS, LAT, ATC