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Three Different Approaches
Comparison of Concussion Grading Scales
Comparison Of Concussion Return-To-Play Guidelines
Prague return-to-play guidelines: A new approach
Similarities And Differences
Which guidelines to follow?
Just Guidelines

Prague Return-To-Play Guidelines: A New Approach

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When a child shows any symptoms or signs of a concussion, the Prague consensus statement recommends that return to play be governed by a step-wise process:

• The player should not be allowed to return to play in the current game or practice;

• The player should be evaluated by a doctor;

• The player should not be left alone and should not drive a motor vehicle.

• The player should be monitored on a regular basis during the first 24 to 48 hours after injury for signs of deteriorating mental status which may indicate a more serious brain injury requiring immediate hospitalization.

• The player should not be allowed to return to play until he has completed the following medically supervised stepwise process:

1. No activity, complete rest. Once an athlete is completely symptom free, proceed to step 2;

2. Light aerobic exercise such as walking or stationary cycling, no resistance training;

3. Sport specific training (i.e. skating in hockey, running in soccer);

4. Non-contact training drills;

5. Full contact training, ideally only after clearance by a medical doctor;

6. Game play.

• If any post-concussion symptoms reoccur, drop back to previous asymptomatic level and try to progress again after 24 hours.

In recommending that any athlete exhibiting concussion signs and symptoms not be allowed to return to play in the same game or practice, the Prague guidelines take a much more conservative approach than the other return to play guidelines provide, and essentially reflects the philosophy "When in doubt, sit out."

Similarities And Differences

While there is no universal agreement on determining the severity of concussions, and when an athlete may return to play, there is unanimous agreement that an athlete still suffering post-concussive signs or symptoms at rest and with exertion should not be allowed to return to contact or collision sports.

Thus, while it is a clinical decision as to when to return an athlete to play after concussion, to return an athlete with post-concussion symptoms risks not only cumulative brain injury, but also a potentially fatal condition called second impact syndrome, and would be against the recommendations of all the major concussion management guidelines.

Which Guidelines To Follow?

National Athletic Trainers' Association

In a position statement on the management of sport-related concussion published in the September 2004 issue of The Journal of Athletic Training, the National Athletic Trainers Association (NATA) refused to endorse any of the three approaches to concussion management, but recommended that certified athletic trainers and team physicians, at the very least, "agree on a philosophy for managing sport-related concussions before the start of the athletic season," and, after deciding on an approach, "be consistent in its use regardless of the athlete, sport, or circumstances surrounding the injury."

American College of Sports Medicine

In its 2006 consensus statement on concussion and the team physician, the American College of Sports Medicine (ACSM):

• while falling short of an unqualified endorsement of the Prague concussion management approach, appeared to endorse its broad outlines in determining severity retrospectively and use of "progressive aerobic and resistance exercise training tests before full RTP";

• Appeared to reject earlier guidelines that focused heavily on LOC and RGA (e.g. the Colorado and AAN guidelines) and endorse the retrospective approach of the Cantu revised and Prague guidelines in viewing RTP guidelines that considered "RGA, PTA, as well as the number and duration of additional signs and symptoms" as "more accurate in predicting severity and outcome бн [and hence] more useful," and by endorsing an individualized RTP decision, not one "based on a rigid timeline" [like the Colorado, AAN and Cantu Revised Guidelines; see above].

• Endorsed the widely-held view that athletes with significant, persistent or worsening signs and symptoms should not return to play the day of injury,

• Recognized that "for other athletes with concussion, significant controversy exists for a same-day RTP decision," but that the "safest course of action" was to "hold an athlete out."

• Recommended use of "progressive aerobic and resistance exercise challenge tests before full RTP," (akin to the stepwise RTP guidelines set forth in the Vienna and Prague consensus statements) and consideration of other factors affecting RTP for an individual athlete, including age, previous concussion history, whether repeated concussions had occurred with progressively less impact force, the sport, and whether the athlete had any learning disabilities (again, falling just short of endorsing the Prague classification for "complex" concussions).

Just Guidelines

It is important to remember that, regardless of which set of guidelines your child's school or sports program follows, the guidelines are just that: guidelines, not ironclad rules. Each case should be reviewed, ideally by a medical doctor, on an individual basis to determine whether your child is able to return safely to sport.

No matter what guidelines are followed, in making return to play decisions, the following factors should be considered:

• The severity of the current injury (especially loss of consciousness longer than 1 minute

• How long the symptoms persist (including persistent symptoms with exertion)

• Whether there has been prolonged cognitive impairment

• Whether the athlete has learning disabilities

• Whether the athlete has suffered repeated concussions over time, and if so, the number, severity, proximity in time to current injury. An athlete with a previous concussion during the season is at 3 to 4 time's greater risk for suffering a second concussion. The risk of concussion increases further after each subsequent concussion. For athletes who have suffered three mild/simple concussions or two moderate-severe/complex concussions in the same season, experts advise that they not be permitted to return to play again that season.

• The sport the athlete is playing. An athlete participating in a non-contact, low-risk sport can, in all likelihood, be returned to play sooner than an athlete returning to a high-risk, collision sport, such as football or wrestling.

• Whether repeated concussions are occurring with progressively less impact force (a factor which would require classification of the concussion as "complex" under the Prague consensus statement

• The athlete's age (developing brain may react differently to trauma than mature brain)

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Author: Lindsay Barton
Date created: January 22, 2008
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