Step One: Rest and Recovery
This is the physical and relative cognitive rest step. The player-patient is prescribed rest, limiting or, if necessary, avoiding activities (both physical and cognitive) which increase or aggravate symptoms until his signs and symptoms and neurologic examination, including cognitive and balance tests, return to baseline status. During this step, the player-patient may engage in limited stretching and balance activity as tolerated at the discretion of the medical staff. Should additional issues present, the team physician should consider external consultation or additional diagnostic examinations.
Once the player-patient is at his baseline level of signs and symptoms and neurological examination, he may be cleared to proceed to the next step.
Neurocognitive testing is administered to assess the player-patient’s level of cognitive function and identify any acute / subacute deficits that would affect his ability to resume normal activities. Neurocognitive testing can be introduced any time after completing Step One, or during Steps Two or Three, as long as it is completed prior to the initiation of contact activities. The timing of neurocognitive testing is up to the team physician with consultation from the team’s neuropsychology consultant. All neurocognitive tests are to be interpreted by the team’s neuropsychology consultant, with the results communicated to the team physician.
Step Two: Light Aerobic Exercise
Step Two involves the initiation of a graduated exercise program. Under the direct oversight of the team’s medical staff, the player-patient should begin graduated cardiovascular exercise (e.g., stationary bicycle, treadmill) and may also engage in dynamic stretching and balance training. The duration and intensity of all activity may be gradually increased so long as the player-patient remains at baseline while performing the activity and for a reasonable period thereafter. If there is recurrence of signs or symptoms the activity should be discontinued. He may attend regular team meetings and engage in film study.
If neurocognitive testing was not administered during Step One, it should be administered during Step Two or Three. If a player-patient’s initial neurocognitive testing is not interpreted as back to baseline by the consulting team neuropsychologist, the tests will be repeated at a time interval agreed upon by the team physician and consulting team neuropsychologist (typically 48 hours). Additionally, a comprehensive evaluation of potential non-injury related causes of a noted neuropsychological decrement should be performed by the team physician. An athlete may be allowed to participate in non-contact activities even if their neurocognitive testing is interpreted as abnormal. The player-patient should not proceed to contact activities until their neurocognitive testing is interpreted as having returned to their baseline level by the consulting team neuropsychologist or, if a decrement persists, until the team physician has determined that this is not due to the concussion. The need and time interval for additional testing will be determined by the team physician, in consultation with the team’s neuropsychology consultant, based on the clinical status of the player-patient.
Once the player-patient has demonstrated his ability to engage in cardiovascular exercise without recurrence of signs or symptoms, he may proceed to the next step.
Step Three: Continued Aerobic Exercise & Introduction of Strength Training
The player-patient continues with supervised cardiovascular exercises that are increased and may mimic sport specific activities, and supervised strength training is introduced. Some may consider this step as a continuation of Step Two. If neurocognitive testing was not administered after Step One, or during Step Two, it should be administered during Step Three. If a player-patient’s initial neurocognitive testing is not interpreted as back to baseline by the consulting team neuropsychologist, the tests will be repeated at a time interval agreed upon by the team physician and consulting team neuropsychologist (typically 48 hours). A player-patient may be allowed to participate in non-contact activities even if his neurocognitive testing is interpreted as abnormal. The player-patient should not proceed to contact activities until their neurocognitive testing is interpreted as back to their baseline level by the consulting team neuropsychologist or, if a decrement is still present, until the team physician has determined a non-concussion related cause. The determination of when to proceed with contact activities is ultimately made by the team physician.
Once the player-patient has demonstrated his ability to engage in cardiovascular exercise and supervised strength training without recurrence of signs or symptoms, he may proceed to the next step.
Step Four: Football Specific Activities
The player-patient may continue cardiovascular conditioning, strength and balance training and participate in non-contact football activities such as throwing, catching, running and other position-specific activities. All activities at this step remain non-contact. (e.g., no contact with other players or objects, such as tackling dummies or sleds).
If the player-patient is able to tolerate all football specific activity without a recurrence of signs or symptoms of concussion and his neurocognitive testing has returned to baseline, he may be moved to the next step in the sequence.
Step Five: Full Football Activity/Clearance
After the player-patient has established his ability to participate in non-contact football activity including team meetings, conditioning and non-contact practice without recurrence of signs and symptoms and his neurocognitive testing is back to baseline, the team physician may clear him for full football activity involving contact. Once cleared by the team physician, the player-patient may participate in all aspects of practice. If the player-patient tolerates full participation practice and contact without signs or symptoms and the team physician concludes that the player-patient’s concussion has resolved, he may clear the player-patient to return to full participation. Upon clearance by the team physician, the player must be examined by the INC assigned to his Club. The INC must be provided a copy of all relevant reports and tests, including the player-patient’s neurocognitive tests and interpretations. If the INC confirms the team physician’s conclusion that the player-patient’s concussion has resolved, the player-patient is considered cleared and may participate in his Club’s next game or practice.
If a player exhibits reoccurring signs of the concussion during any point in the process, they return to the prior step.
