1. Concussion / Mild Traumatic Brain Injury Return to Participation Protocols 2014 First Coast Sports Injury Symposium Concussion Workshop Jim Mackie, Med, ATC, LAT

2. 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.

3. 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

4. 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.

5. 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?

6. 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

7. 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

8. Six step process – AT18 1. No Activity - Recovery 2. Light aerobic exercise 3. Sport – specific exercise 4. Non-contact training 5. Full Contact practice 6. Return to full activity

9. 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

10. 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

11. 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

16. 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

20. 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

21. 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…

22. 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

23. As an athletic trainer or other healthcare provider your initial and on-going clinical interviews will assist the MD with their treatment plan.

24. Local Resources for RTP Help? Identify the Schools Athletic Trainer Local Rehab Centers that may offer supervised program

25. Physician Communication Office visit or not? Depends upon physician (MD/DO) Trust in person monitoring daily progress with Athletic Trainer, Coach, Therapist, etc.

26. 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

27. 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

28. 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.

29. 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.

30. Thank You Jim Mackie, Med, ATC, LAT Jacksonville Sports Medicine Program