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Return to Play Progression After A Concussion

Concussions are the hot topic across all of sports. For the past 20 years, the concept of not participating in sports while symptomatic has been known. The big question now is how long should one wait after symptoms stop before returning to the field?

As recently as 5 years ago, an athlete could return to the field if his or her symptoms resolved quickly and didn’t come back for 20 minutes. Those were the days of getting “your bell rung” and thankfully are long gone. Now, most professional sports require removal for the day of the player after suffering a concussion.  At the high school level, any player suspected of suffering a concussion must be removed from participation and is not allowed to return to play unless they have a written note from a physician.     

There is still debate over how long a player should be removed from competition after suffering a concussion. Recommendations by some physicians say that youths that have suffered a concussion should be withheld from physical activity for 3 months. 

Return to play should be proportional to duration of symptoms. If the concussion symptoms are mild and resolve within seconds/minutes, then 24 hours may be enough to start this program. However, if symptoms are present for weeks after the injury, do not begin this program after your first 24 hours of being symptoms free. Give yourself more time. Past recommendations have given a 1:1 or a 1:2 ratio.  Meaning that if you are symptomatic for 7 days post-injury then you should have 7 days (or 14 days in the 1:2 ratio) prior to beginning a return to play program.

This return to play protocol below is based on the latest recommendations, available knowledge of concussions, and various protocols that are being used including MLS and Prague. The Prague Guildines are considered the most up to date with current research and are the basis for many sports guidelines. This program can be considered conservative and may be better suited for younger players.

Because every concussion and every athlete is different, it is impossible to give a definitive time frame for each phase. The more severe and/or longer the duration of symptoms, the more days should be spent at each step. If you have symptoms, you cannot progress to the next step. You must wait 24 hours after symptoms resolve before a step can be repeated. However, if symptoms return at a certain phase multiple times, then you must stop and return to that previous phase again.

Remember, always err on the side of caution. Do not begin this program until you are cleared and have discussed this progression with your physician.

Step 1: Light bike for 20 minutes. This is the beginning step of increasing your blood pressure. You do not want to elevate your heart rate above 140 in step 1.

Step 2: Advance biking. Gradually increase your heart rate and duration.

Step 3: Fast Walking. Go for a fast paced walk. It should be at the speed where it would be easy to break into a light jog and fast enough to raise your blood pressure slightly. The purpose of the walk is to see how your body tolerates a slight elevation in blood pressure and the gentle impact with the ground. The total time for this should be 15 minutes. If this is the first time that you are outside, it is best to wear a hat or sunglasses. Photophobia (problems with light) can be a symptom of an unresolved concussion. At this point we do not want to introduce new elements as you work your way back. Should symptoms return when you are outside for the first time, then you are faced with the question: was it the sun or the increase in blood pressure that caused the symptoms to return?

Step 3b: Walk-jog (for more severe concussions). 

Step 4: Light jog. Go for a light jog. The pace of the jog should be at the level where you can still converse with someone.

Step 5: Distance jog. Increase the pace and distance of the jog.

Step 6: Interval running. Open up your stride the length of the field and have a slow recovery jog on the end lines. The sideline sprint does not need to be a full sprint and can be in the 70% range.

Variation (shorten the distance sprinting): Sprint along the midfield line, recovery jog along sideline from midfield line to corner flag, Sprint end line, recovery jog sideline from corner flag to midfield. 

Step 7: Soccer Specific Movement:

Cutting - Cutting can be done in a variety of ways. Setting up cones in a pattern. Agility ladder can be used. 

Cutting should be initially done in a pre-programmed format. For example a 15 x 15 yard box with a cone in the middle. The player runs from the center cone to each outer cone in a clockwise (or counter clockwise) direction. Once the athlete has mastered this drill, number the cones 1 -4.  Have the athlete start in the middle cone and whoever is assisting them with their workout (preferably a Certified Athletic Trainer or other medical professional) randomly chooses a cone for the player to run too. 

Step 8: Introduction of a ball:

Once an athlete has demonstrated that they are able to functionally handle the various physical stresses of running and cutting, then the ball can be introduced for both a heading standpoint and soccer skills standpoint. They can be done simultaneously as long symptoms do not return.  

Step 8A: Heading needs to be introduced gradually. The heading progression is as follows:

1.       5 yards light toss x 3 directions: forward , to the left, and to the right.

2.       Increase the distance to 10 yards. The number of throws may be increased as well.

3.       Increase the distance to 20 yards. The number of throws may be increased as well.

4.       Increase the height and/or velocity of the ball tosses.

5.       Kicked soccer balls. Begin chipping crosses into player or serving flighted balls.

Step 8b: Individual skill drills

Once a player has completed all of these steps, they can begin a gradual return to play.  

Soccer specific drills- this can be any combination of individual dribbling, trapping, or passing drills. The player should start individually and then progress into team skill drills such as a team passing drill.

Step 9: Restricted training: Player should initially train as a neutral, preferably without contact from teammates. This allows the player to assimilate playing again. From there, the player can progress to training without heading.

Step 10: Full training: Return to full training. Players should have several sessions of full training prior to returning to a game setting. If they have been out for an extended period of time then they should spend extra time at this step.

Remember if you have been out for an extended period of time, your overall fitness may have declined. Don’t put yourself for injury to other body parts by player before you are fully fit. 

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