In some circumstances – such as professional clubs, international teams and academies – there may be a enhanced level of medical care available. This allows closer supervision of a player’s care and graduated return to play (GRTP).
In these instances, a shorter time frame for return to play (RTP) may be possible, but only under strict supervision by the appropriate medical personnel as part of a structured concussion management programme. If these conditions are met, you may be able to follow the 'Return to play pathway in an enhanced care setting' (this is never suitable for players under 16).
The minimum criteria for this pathway are as follows:
1. There's a doctor with training and experience in the management of concussion or traumatic brain injury in sport available to closely supervise the player’s care and GRTP, and clear the player prior to RTP.
2. There is a structured concussion management programme in place for the player as outlined below:
- Baseline SCAT5 and/or computerised neuro-psychometric/cognitive testing of the player has been conducted prior to the injury.
- Clinical serial multimodal assessment of the player occurs post-concussion to guide the recovery protocol.
- Acknowledging that more than one area of brain function can be affected by concussion, this will involve formal documented assessment of areas such as cognitive function, emotional wellbeing, neurological function and any physical trauma sustained.
- A formalised GRTP programme with regular SCAT5 or equivalent assessments is followed and recorded in the player’s medical records
- The player has access to a multi-disciplinary team including neuropsychology / neurology / neurosurgery specialists and other clinicians as required to supervise the return to play and instigate any treatment or investigation required should the RTP progression not be straightforward.
- A formal and documented concussion education programme exists for coaches and players in the club or team involved.
If any element of the above criteria is absent, the player should follow the 'Standard return to play pathway'.
Rest the body, rest the brain
Rest is the cornerstone of concussion treatment. This involves resting the body, ‘physical rest’, and resting the brain, known as ‘cognitive rest’. The period of rest allows symptoms to recover and in the non-professional setting allows a return to work or study prior to resuming training and playing.
Rest means avoiding:
- physical activities such as running, cycling, swimming, physical work activities, etc
- cognitive activities (thinking activities), such as school work, homework, reading, television, video games. Students with a diagnosis of concussion may need to have allowance made for impaired cognition during recovery, such as additional time for classwork, homework and exams.
Anyone with a concussion or suspected concussion should not:
- be left alone in the first 24 hours
- consume alcohol in the first 24 hours, and thereafter should avoid alcohol until free of all concussion symptoms
- drive a motor vehicle and should not return to driving until provided with medical or healthcare professional clearance or, if no medical or healthcare professional advice is available, should not drive until free of all concussion symptoms.
Returning to play after a concussion
The graduated return to play (GRTP) protocol should be followed in all cases.
This staged programme commences at midnight on the day of injury and stage 1 (initial rest period) is 14 days in all players unless they are in an enhanced care setting. In all cases, progression to stage 2 of the GRTP can only occur if the player has no symptoms
Return to work and study after a concussion
At the non-professional level, adults must have returned to normal education or work and students must have returned to school or full studies before starting physical activity (stage 2) in a GRTP program.
Graduated return to play protocol
A graduated return to play (GRTP) protocol is a progressive exercise program that introduces an individual back to sport in a step wise fashion.
Stage 2 of the GRTP protocol should only be started when a player:
- is symptom free at rest and has completed the initial rest period (14 days in a standard care setting and modified in an enhanced care setting)
- has returned to normal education or work if not a professional footballer
- is not receiving treatments and medications that may mask concussion symptoms, e.g. drugs for headaches or sleeping tablets.
The GRTP Protocol contains six distinct stages:
Under the GRTP Protocol, the individual can advance to the next stage only if there are no symptoms of concussion at rest and at the level of physical activity achieved in the current GRTP stage.
If any symptoms occur whilst going through the GRTP program, the individual must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms (this is 48 hours in players under 19 years of age).
It is recommended that a medical practitioner confirms recovery before an individual enters Stage 5 (full contact practice).
The six-stage GRTP protocol should be followed in all cases. Stages 2-5 take a minimum of 24 hours in adults, 48 hours in those aged 19 and under.
Return to play pathway in an enhanced care setting
The minimum time in which a player can return to play in the Enhanced Care Setting is summarised by the table below. Each day comprises one 24 hour period. The pathway begins at midnight on the day of injury.
It is recognised that players will often want to return to play as soon as possible following a concussion. Players, coaches, management, parents and teachers must exercise caution to ensure that:
- all symptoms have resolved before commencing GRTP
- the GRTP protocol is followed
- the advice of medical practitioners and other healthcare professionals is strictly adhered to.
After returning to play, all those involved with the player, especially coaches, support staff and parents must remain vigilant for the return of symptoms even if the GRTP has been successfully completed.
If symptoms recur the player must consult a healthcare practitioner as soon as possible as they may need a referral to a specialist in concussion management.
How are recurrent or multiple concussions managed?
Any player with a second concussion within 12 months, a history of multiple concussions, players with unusual presentations or prolonged recovery should be assessed and managed by a healthcare provider with experience in sports-related concussions working within a multidisciplinary team.
Outcomes in concussion are better if the injured player is well informed and understands what has happened. Measures to improve understanding and deal with emotional problems and anxiety should also be considered in the management of concussed players.