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 GRTP/S steps at Steps 4, 5 and 6
SCHOOL TEAM / PHYSICAL
Often, the school’s athletic trainer (AT) helps the student go through the Gradual Return to Sport/Play (GRTS/P) steps. According to the 2022 Amsterdam guidelines, a healthcare provider (HCP) may allow some light exercise (like cardio) in the early steps—steps 1, 2A, 2B, and 3—even if the student still has some symptoms.
Before moving to the later steps (4, 5, and 6), two things must happen:
The student is back to their normal functioning in all areas without symptoms (see Criteria Towards Clearance).
They have approval from an HCP to start Step 4.
If a student doesn’t have an AT, or if it’s a younger child or non-athlete, it’s still best practice for an HCP, outpatient physical or occupational therapist, or parent/guardian to supervise the GRTP/S steps.
WHEN ALL FOUR TEAMS AGREE...
that the student or athlete is completely back to their normal pre-concussion abilities, the HCP can approve the start of the Gradual Return to Play/ Sport (GRTP/S) Step 4.
Adding physical activity in slowly is the last test for the brain. If the student can increase exercise without symptoms coming back, the concussion is considered fully healed. This step is the final and safest way to give formal “clearance” and protect against a more serious or second injury.
NOTE: An HCP gives "approval" to start GRTP/S steps. An HCP cannot give "clearance" of the concussion until successful completion of all of the GRTP/S steps.
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