Returning to play after a head injury requires a systematic approach to ensure an athlete’s safety. To navigate this process, we present clinical guidelines designed to lead athletes, coaches, parents, and healthcare professionals through the intricate steps of concussion recovery and clearing an athlete for return to play. We aim to provide the tools necessary to make informed decisions prioritizing the athlete’s well-being above all else.
Research has indicated that while the symptoms of concussion subside relatively quickly for some, this does not necessarily equate to a complete concussion recovery. In fact, studies have shown that factors such as balance, reaction time and exercise tolerance can have persistent deficits even after symptoms have resolved. More specifically, studies have shown ~15% (1) of athletes with no symptoms fail the “Chicago Blackhawks Test” (i.e., Gapski-Goodman Test), an evidence-based physical exertion test. In addition, reaction time has been shown to be impaired for up to 21-59 days and balance measures can be off for 30 days. This underlines the importance of adhering to a gradual return-to-play protocol, ensuring that athletes do not rush back into intense activity prematurely, potentially risking a second brain injury and serious consequences.
Returning to sport too soon after a head injury can have severe consequences, one known as Second Impact Syndrome. Second Impact Syndrome (SIS) is an exceedingly rare, but potentially fatal condition that can occur if an individual sustains two or more head impacts too close together temporally (i.e., within ~1 week of the initial impact).
Second Impact Syndrome results in rapid and severe brain swelling that can lead to long-term disabilities or even death. The risk of Second Impact Syndrome underlines the importance of ensuring athletes have fully recovered before returning to play, highlighting the need for adherence to a carefully monitored return-to-play protocol.
Throughout each stage, the athlete’s symptoms are closely monitored, and athletes are encouraged to promptly communicate any symptom changes.
Advancement to the next stage only occurs when the athlete remains symptom-free throughout the current stage, and each stage must last at least 24 hours. If symptoms re-occur at any point, the athlete should step back to the previous stage (e.g., Stage 4 to 3).
Return-to-play (RTP) decisions, particularly for young athletes or those with a history of multiple concussions, require careful consideration. It’s essential to take into account the athlete’s age, recovery time, the number of previous brain injuries, and the interval between concussions. Sports career-ending decisions must be made between all healthcare providers, the athlete’s family, teachers, and coaches/trainers. It’s an important decision to be made by everyone, prioritizing the athlete’s safety and long-term health.
After a suspected sports-related concussion, immediate action is crucial. Athletes, coaches, trainers, and physical therapists should follow these initial steps:
Returning to sports after a head injury is a carefully planned process that includes a graduated exercise protocol that ensures athletes safely return to play while minimizing the risk of worsening symptoms or a second concussion. Here’s a step-by-step plan:
The first 24-48 hours following a traumatic brain injury should include physical and cognitive rest. The next few days (72 hrs), research emphasizes the importance of engaging in light activity, such as walking, stationary cycling, and activities of daily living, as long as these activities do not increase concussion symptoms or create new symptoms.
Contrary to the outdated “rest-until-symptom-free” approach, current evidence suggests that incorporating light aerobic activity into the concussion treatment regimen can minimize symptoms and expedite healing. However, this activity must stay within a safe threshold, not worsening symptoms or putting the athlete at risk for hitting their head, as the brain remains vulnerable to additional injury during this period. 2-10 days after a head injury, it is time to find a threshold for activity that does not provoke symptoms. This is done by completing a Buffalo Concussion Treadmill Test (BCTT) with a concussion specialist. The BCTT is a submaximal stress test that helps determine the athlete’s functional capacity and tolerance for physical exertion.
Read more about the BCTT here.
If the athlete passes the BCTT, then they progress to stage 3. If the athlete fails the BCTT, they are given a sub-symptom exercise program to complete and are retested in a week. They may not move to stage 3 until they pass the BCTT.
In this stage, athletes gradually introduce light sport-specific drills and exercises with their team or individually, such as light skating, passing drills, etc. in ice hockey. Athletes should not engage in any team-based drills where there could be accidental contact.
As mentioned above, each stage must last at least 24 hours without an increase in symptoms.
At this stage, athletes can join their teams for non-contact training drills. These drills should be higher intensity and more complex, but still with no concussion risk due to incidental contact. Athletes can also begin progressive resistance training exercises.
Remember, athletes should not advance to the next stage unless they can complete these drills without experiencing a resurgence of symptoms. If the athlete completes stage 4, is completely asymptomatic, and goes back to full-time school/work, the athlete can progress to stage 5 for clearance. If concussion symptoms worsen, they go back to Stage 3.
In the final stage of clearance, once an athlete is entirely symptom-free and back to full-time school/work, tests like the “Chicago Blackhawks Test” (i.e., Gapski-Goodman Test) + Baseline Retest and/or Vestibular Ocular Motor Screening (VOMS) are utilized to assess an athlete’s readiness to return to full contact play. These assessments provide a comprehensive overview of the athlete’s neurological function and readiness to reintegrate fully into sport.
The Chicago Blackhawks test, also called the “Gapski-Goodman Protocol,” for return to sports clearance is a tool used in the final stages of concussion recovery. Conducted by a trained healthcare provider, this test measures an athlete’s physical readiness to return to full-contact training and competitive play. This test can assess functional skills, including balance, coordination, and physical endurance, ensuring the athlete can safely resume sports without risking a recurrent concussion.
Read more about the Chicago Blackhawks Test here.
Following a concussion, a crucial part of the athlete’s recovery process is meeting their pre-injury baseline scores that should have been completed in the past year. Baseline testing is a collection of pre-season assessments that measure an athlete’s normal brain function. For example, these tests measure balance, cognitive function, reaction time, and concussion symptoms.
After a brain injury, these tests are retaken, and the results are compared to pre-injury baseline scores. The athlete is considered for a return to play once their post-injury scores meet or exceed their pre-injury baseline scores across all measures. This is to ensure that they have full cognitive recovery from their concussion.
Read more about the baseline test here.
In situations where an athlete’s baseline scores are unavailable , or the baseline test was completed over one year ago, the VOMS test can help determine readiness to return to sport. This screening evaluates the athlete’s ocular and vestibular systems, commonly affected by concussion.
An athlete should have no symptoms during or after the VOMS testing to be considered ready for full reintegration into sports. Although it’s preferable to have pre-injury baseline scores for comparison, the VOMS offers a reliable alternative for assessing an athlete’s post-concussion condition in the absence of such data.
Read more about the VOMS test here.
High-risk athletes playing contact sports must successfully pass the Blackhawks test in addition to either the Baseline or VOMS before progressing to Stage 6 of the recovery protocol. If the athlete fails any of these tests, they return to stage 4.
For athletes participating in non-contact sports, it is mandatory to successfully pass either the Baseline or the VOMS before advancing to Stage 6. If the athlete fails either of these tests, they return to stage 4.
Following medical clearance, the final stage involves a return to normal activities and normal gameplay. Athletes must resume contact practice and normal training activities with team drills and scrimmages before playing in an actual game. If the athlete completes a full-contact practice with no symptoms, they can return to games. If symptoms return, the athlete steps back to Stage 5. At Complete Concussions, we like our athletes to complete more than one full-contact practice to ensure they feel physically and psychologically ready to return.
Furthermore, our return-to-play protocol aligns seamlessly with the principles laid out in the most recent Amsterdam Concussion Statement. See below for more details.
The safe return to sports following a mild traumatic brain injury is of paramount concern. This comprehensive guide has discussed the critical aspects of concussion recovery, emphasizing the importance of athlete safety and well-being above all else. The journey to recovery from a concussion is a challenging one, but with the right guidance and a commitment to safety, athletes can return to play the sports they love.
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