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 ▶ Parent ▶ Coach ▶ Athlete ▶ Avid Sports Fan ▶ Sports Physician

Goals 1. Understand the evolution of the return to play criteria for concussion 2. Be aware of the current return to play algorithm for concussion 3. Gain an understanding of the challenges with return to play decision making

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Return To Play ▶ Why do we care? ▶ Repetitive head trauma –Contact sports –Physical abuse –Epileptic seizures –Head banging ▶ Slowed recovery, cognitive impairment, ▶ Behavioral dysregulation, mood disorders, Neurodegeneration »Gavett et al 2011, McKee et al 2009

In The Classroom ▶ 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: , 1999].

DECISION MAKERS ▶ Who says its OK to go back to play? –Athlete –Parents –Coach –Agent –ATC –Physician

Return To Play ▶ “ 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) ▶ During school athletic activities schools are required to remove from activity any student suspected of sustaining a mild traumatic injury (“concussion”) ▶ 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 ▶ Rest ▶ Expect gradual resolution in 7-10 days ▶ Start graded exercise rehabilitation when asymptomatic at rest and post-exercise challenge

Sports concussion ▶ How long asymptomatic before exercise? –If rapid and full recovery, then 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 ▶ 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 24 hours per step If there is recurrence of symptoms at any stage, return to previous step Rehabilitation stageFunctional exercise at each stage of rehabilitation Objective of each stage 1. No activityComplete physical and cognitive rest.Recovery 2.Light aerobic exerciseWalking, swimming or stationary cycling keeping intensity < 70% MPHR No resistance training. Increase HR 3.Sport-specific exerciseSkating drills in ice hockey, running drills in soccer. No head impact activities. Add movement 4.Non-contact training drillsProgression 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 practiceFollowing medical clearance participate in normal training activities Restore confidence and assess functional skills by coaching staff 6.Return to playNormal game play

Return To Learn As symptoms improve, a return to learn plan can include ▶ Shorter school days ▶ Rest periods ▶ Extended time for tests/homework/class work ▶ Peer note takers ▶ Audiotapes of class 16

Persistant Symptoms ▶ 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. Understand the evolution of the return to play criteria for concussion 2. Be aware of the current return to play algorithm for concussion 3. Gain an understanding of the challenges with return to play decision making

THANK YOU ▶ 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