Concussion Return to Play (Sports Med) Rehabilitation Protocol

This protocol outlines a comprehensive, stepwise approach to rehabilitation following a concussion in athletes, aiming to safely return them to sports participation. This protocol emphasizes a gradual increase in activity, monitoring for symptom exacerbation, and individualized progression based on tolerance.

I. Pathophysiology of Concussion

Concussion, also known as mild traumatic brain injury (mTBI), is a complex pathophysiological process affecting the brain, induced by biomechanical forces. It typically results in a neurometabolic cascade triggered by ionic shifts, leading to altered neurotransmitter release, impaired cerebral blood flow, and energy deficits. While structural damage is usually not visible on standard imaging, the functional impairment can lead to a variety of symptoms, including headache, dizziness, cognitive deficits, and emotional changes. The severity and duration of symptoms are highly variable.

• Neurometabolic Cascade: Disruption of ion homeostasis (K+ efflux, Na+ influx) leads to neuronal depolarization.
• Energy Crisis: Increased energy demand coupled with reduced cerebral blood flow creates an energy deficit.
• Neurotransmitter Imbalance: Altered release of excitatory and inhibitory neurotransmitters.
• Inflammation: Activation of inflammatory pathways can contribute to prolonged symptoms.

II. Phase I: Acute Rest and Protection

Goal: Reduce initial symptoms and promote cerebral recovery. Physical and cognitive rest are paramount during this phase.

• Activity Level: Complete physical and cognitive rest for the first 24-48 hours, or until symptom free at rest. This includes avoiding strenuous activity, sports, prolonged screen time, reading, and complex problem-solving.
• Symptom Management: Address specific symptoms with appropriate interventions.
  • Headaches: Medication as prescribed by a physician. Consider gentle cervical ROM exercises if appropriate and not exacerbating symptoms.
  • Dizziness/Nausea: Vestibular rehabilitation exercises (eye movements, balance training) may be initiated after a period of complete rest, only if guided by a physical therapist specializing in vestibular rehabilitation and only if they do not exacerbate symptoms.
  • Sleep Disturbances: Establish a regular sleep schedule, avoid caffeine and alcohol before bed.
• Progression Criteria: Remain symptom-free at rest for at least 24 hours before progressing to Phase II. Any increase in symptoms necessitates a return to the previous stage.

III. Phase II: Gradual Loading and Symptom-Limited Activity

Goal: Begin a graduated return to activity while monitoring for symptom exacerbation. This phase focuses on light aerobic exercise and cognitive activities, progressively increasing in intensity.

• Step 1: Light Aerobic Exercise:
  • Activity: Low-intensity walking or stationary cycling at a comfortable pace.
  • Intensity: Target heart rate should remain below 70% of maximum heart rate.
  • Duration: 15-20 minutes.
  • Progression Criteria: No increase in baseline symptoms during or after the activity.
• Step 2: Increased Aerobic Exercise:
  • Activity: Jogging or increased intensity on stationary cycling.
  • Intensity: Target heart rate between 70-80% of maximum heart rate.
  • Duration: 20-30 minutes.
  • Progression Criteria: No increase in baseline symptoms during or after the activity.
• Step 3: Sport-Specific Exercise (Non-Contact):
  • Activity: Drills specific to the athlete's sport that do not involve head impact (e.g., dribbling, passing, shooting).
  • Intensity: Gradually increase the intensity and duration of drills.
  • Progression Criteria: No increase in baseline symptoms during or after the activity.
• Monitoring: Closely monitor symptoms using a standardized symptom scale (e.g., Post-Concussion Symptom Scale – PCSS).
• Regression: If symptoms increase at any point, the athlete should return to the previous step until symptoms resolve.

IV. Phase III: Return to Sport-Specific Training and Return to Play

Goal: Full return to sport, including contact activities, with confidence and no return of symptoms.

• Step 4: Non-Contact Training Drills:
  • Activity: More complex sport-specific drills that may involve agility, coordination, and higher intensity, but still without contact.
  • Duration: Gradual increase in duration and complexity.
  • Progression Criteria: No return of symptoms after training sessions.
• Step 5: Full Contact Practice:
  • Activity: Participation in regular team practices with full contact.
  • Duration: Start with limited contact and gradually increase to full practice participation.
  • Progression Criteria: No return of symptoms during or after practices.
• Step 6: Return to Play:
  • Criteria: Medical clearance from a physician is required before returning to competition. The athlete must be symptom-free at rest and with exertion, and have successfully completed all previous stages.
  • Considerations: Consider a graded return to competition, starting with limited playing time.

V. Common Special Tests and Assessments

The following tests are often used to assess various aspects of concussion and guide rehabilitation:

• Balance Error Scoring System (BESS): Evaluates postural stability.
• King-Devick Test: Measures rapid number naming and saccadic eye movements.
• Vestibular Ocular Motor Screening (VOMS): Assesses vestibular and ocular motor function (smooth pursuits, saccades, convergence, VOR).
• Cognitive Testing (SCAT5, ImPACT): Evaluates cognitive function (memory, attention, concentration).
• Cervical Spine Assessment: Examines range of motion, muscle tenderness, and joint dysfunction in the cervical spine. Rule out cervical spine injury if indicated.
• Post-Concussion Symptom Scale (PCSS): Quantifies the severity of concussion symptoms.
• Buffalo Concussion Treadmill Test: Determines heart rate at which symptoms increase; used to prescribe aerobic exercise.

Important Considerations:

• This protocol is a guideline and should be individualized based on the athlete's specific symptoms, medical history, and sport.
• Close communication between the athlete, parents, coaches, physicians, and physical therapists is essential.
• Early intervention and appropriate management can significantly improve outcomes following a concussion.
• If symptoms persist beyond the expected recovery timeframe, referral to a concussion specialist may be warranted.