STEP 4: PACE
FAMILY TEAM
Is the student 100% back to pre-concussion home functioning?
SCHOOL TEAM / ACADEMIC
Is the student 100% back to pre-concussion academic functioning?
HEALTHCARE PROVIDER TEAM
Approves the start of RTS/P steps at steps 4, 5 and 6
SCHOOL TEAM / PHYSICAL
Often the AT at the school takes the athlete through the GTS/P steps. With the 2022 Amsterdam guidelines, a HCP may introduce sub-threshold exercise (aka cardio) at steps 1, 2A, 2B and 3 while still symptomatic but the student must be 1.) back to pre-concussion functioning (without symptoms) in all areas and 2.) have HCP approval before starting steps 4, 5 and 6.
If there is no AT available for an athlete or if it is a non-athlete or younger child, it is still best practice for an HCP, outpatient PT/OT or the parent to supervise GRTS/P steps.
WHEN ALL FOUR TEAMS AGREE
that the student/athlete is 100% back to pre-concussion functioning, the HCP TEAM can then approve the start of the Graduated RTS//P steps. The gradual re-introduction of physical activity outlined below is the last test of the brain cells - if physical exertion can be increased without a return of symptoms - the concussion is assumed to be fully healed. This is the final and formal step toward "clearance" and the safest way to guard against a more serious (or second) injury.
Graduated Return-to-Sport (RTS) Strategy – A minimum of 24 hours between steps
Step 1
Symptom-limited activity
Daily activities that do not exacerbate symptoms (e.g. walking).
Gradual reintroduction of work/school
Step 2
Aerobic Exercise
2A – Light (up to approximately 55% of max HR) then
2B – Moderate (up to approximately 70% maxHR)
Stationary cycling or walking at slow to medium pace. May start light resistance training that does not result in more than mild and brief exacerbation* of concussion symptoms.
Increase heart rate
Step 3
Sport-specific exercise
Sport-specific training away from the team environment (e.g. running, change of direction and/ or sport-specific training drills away from the team environment). No activities at risk of head impact.
Add movement, change of direction
Steps 4-6 should begin after the resolution of any symptoms, abnormalities in cognitive function and any other clinical findings related to the current concussion, including with and after physical exertion.
Step 4
Non-contact training drills
Exercise to high intensity, including more challenging training drills (e.g. passing drills, multiplayer training), can integrate into a team environment.
Resume usual intensity of exercise, coordination and increased thinking
Step 5
Full contact practice
Participate in normal training activities.
Restore confidence and assess functional skills by coaching staff
Step 6
Return to sport
Normal game play.
* Mild and brief exacerbation of symptoms (i.e. an increase of no more than 2 points on a 0-10 point scale for less than an hour when compared with the baseline value reported prior to physical activity) within 24 hours of injury, with progression through each subsequent step, typically taking a minimum of 24 hours. If more than mild exacerbation of symptoms (i.e. more than 2 points on a 0-10 scale) occurs during Steps 1-3, the athlete should stop and attempt to exercise the next day. Athletes experiencing concussion-related symptoms during Steps 4-6 should return to Step 3 to establish full resolution of symptoms with exertion before engaging in at-risk activities. Written determination of readiness to RTS should be provided by an HCP before unrestricted RTS as directed by local laws and/or sporting regulations.
HCP, healthcare professional; maxHR, predicted maximal heart rate according to age (i.e. 220-age).
Rehabilitation Note
The 6th consensus statement suggests: Recommending strict rest until complete symptom resolution is not beneficial to patient recovery. The revised return to sport strategy includes stages 1-3 that fall under concussion treatment/rehabilitation and may be done when a patient has symptoms. Stages 4-6 assists patients in returning to full competition. During the first three stages, patients are encouraged to become progressively more active, as long as it only exacerbates symptoms mildly and symptom exacerbation resolves upon cessation of the activity. Stages 4-6 should be done following resolution of concussion-related symptoms and impairments. Tamara Valovich McLeod, PhD, ATC, FNATA, FNAT, FNAP, Chair, Department of Athletic Training, A.T. Still University