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Concussion: Return to Play

Mizuho Morrison, DO and Matt Baird, MD
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Let’s talk about the controversial topic of returning to play after a head injury. When is it safe?

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Aaron -

This is something that comes up all the time and is sure to get more common as "awareness" increases. We hope it helps you guys. Let us know!

Arthur R. -

I realize that there are 5 stages a child or adult must graduate to for recovery:
1. No activity.
2. Light aerobic activity.
3. Sport-specific exercise.
4. Full-contact practice.
5. Return to normal game play.
Typically, how many appointments should a child come in for to be re-evaluated and how much of this can a parent do at home?

Neda F., MD -

Hi Arthur. I asked Dr. Matt Baird for his thoughts, and he shared the following, which incorporates newer recommendations that have come out since this conversation was released in 2014. -- Neda

"Great question, Arthur, and thanks so much for reaching out. You are essentially correct with your return to sport progression. A couple of nit picky additions:

1. The recommendation for "No Activity" has changes to "Limited/subthreshold activities". Several recent studies, especially the Levy study that has been featured on many Hippo Education podcasts, have convinced most SM physicians that an active rehabilitation is better than no activity. This means that we encourage light aerobic activity (usually walking or stationary biking) during the initial phase of their recovery as long as it does not significantly increase symptoms.

2. For stages 2-3 of your progression in your email we recommend a gradual increase in exercise intensity over a period of 3 days. Below is the progression that we use in our system (very similar to all SM protocols that I am familiar with). If a player becomes symptomatic they move back to asymptomatic stage for 2-3 days before trying again.

-Stage 1: Stationary bike, moderate intensity for 20 minutes
-Stage 2: Bike intervals: hard 30 s, easy 30s for 20 minutes, push-ups and sit-ups (25-50 each)
-Stage 3: Shuttle runs (sprints), push-ups, sit ups, squats, box jumps, etc for 20-30 minutes total
-Stage 4: Non-contact practice
-Stage 5: Full Practice
-Stage 6: Full play

3. Regarding follow up visits: For typical concussions which resolve within 1-4 weeks, I endorse that patients be seen just once after their initial assessment. The ideal timing for this is after stage 3 or 4, before contact activities. As long as they have remained asymptomatic, I will "clear them to complete the RTP back to full participation as long as asymptomatic". The protocol can be supervised by an Athletic Trainer (ideal) if they have one for their team, or a parent. At their initial visit I will write it out for them in enough detail that they can follow it at home. If no access to bike, I substitute running with decreased times.

For complex concussions with prolonged recovery periods (>4 weeks) I try to see patients back every month during their symptomatic phase to re-evaluate. Once asymptomatic they can proceed through the protocol and be cleared as above. For those with super prolonged recovery times (6-12 months+), I will often augment/extend the protocol, but otherwise I stick to it.

I hope this is helpful. Feel free to reach out with other questions."

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All Roads Lead to Cheese Fries Full episode audio for MD edition 220:38 min - 104 MB - M4AHippo Primary Care RAP August 2014 Written Summary 559 KB - PDF