Concussion is obviously a major buzz word, and if you’re in a medical profession and or working with athletes it is more than that, it is something we have to work with. Unfortunately, it is something that we still don’t know a lot about. We are steadily learning more and adjusting how we treat and handle them on a regular basis. There are many good guidelines out there for coaches, PE teachers, athletic trainers, nurses, doctors, etc. to use, and they are good, but they could be better.
In June of 2012 New York State passed The Concussion Management Awareness Act which went into effect on July 1st, 2012. This law led to the development of The Guidelines for Concussion Management in the School Setting. These guidelines were based on the 2008 Zurich Consensus Statement on Concussion in Sport. A new consensus statement came out in November of 2012, with no significant changes in regards to the graduated return to play protocol (RTPP) (Zurich 08 page 4/758, Zurich 12, NY page 11). It is this RTPP and its implementation and monitoring that is my concern.
As an athletic trainer I have found the new law to be a great. So much of it is clearly defined, and there is no argument. If player, parent, coach (fortunately none of mine) question any decisions in regards to pulling an athlete from activity and restricting them it is very easy to point to the law as the reason. My hands are tied, not my decision dad, little Johnny has to sit. Unfortunately, when it comes to implementing and monitoring the RTPP, things become a little more difficult.
How do you explain to an athlete, coach, parent, etc. what low level activity is? How do you control it to make sure that the athlete is complying? Performance standards don’t really work. For most of my high school athletes a 6 minute mile is either very hard or impossible, but I’ve known cross country runners that can whip one out so casually that it is barely a warm up for them. And, no matter how well you know the kid, how can you truly tell how they are pushing themselves? It is just as important to know that the kid isn’t pushing too hard during their RTPP as it is to know they are pushing hard enough. Don’t want a kid to be released for full return and go into a game without having properly tested themselves beforehand.
In the first year of the law I tried to describe to the athlete what level I was looking for. For example, in step 1 I would say that they should peddle hard enough on the exercise bike that they felt like they were putting out some effort, but they should still be able to talk very comfortably and easily. In step 2 talking while running should be able to talk easily, but it should take a little more effort. Each step it would get a little harder for them to talk, breathe, etc. but this could easily be faked for whoever was monitoring them. The intent of the RTPP is to start with a low level of physical stress, make sure the athlete can handle it without return of symptoms or any difficulty, and then step it up. Each step should increase, but limit stress making sure the athlete can safely handle it before increasing to the next step. No matter what I did though, I wasn’t sure whether the goals were truly being achieved.
I don’t remember exactly what it was that prompted the thought, but sometime during a series of lectures on concussions at EATA symposia last January (2013), I came up with the idea to use heart rate to monitor and control my athletes as they went through RTPP. I spoke with a number of other athletic trainers that weekend and all agreed that it seemed like a great idea. The only problem was buying the heart rate monitors, which could eat up a lot of budget, and designing the heart rate parameters for each step of the RTPP. Especially since I had to keep within the existing protocol from the state and not allow something that would possibly range outside of their parameters.
Over the next couple months I didn’t think about it too much because I knew it wouldn’t be until the following school year that I could attempt to work the monitors into my budget. I didn’t table it totally and kept it percolating in the back of my mind. That summer I started putting some of my ideas down onto paper. I did some research to see if I could find anything relating to it, but there wasn’t much out there. There was plenty on heart rates, zones, effort levels, but nothing that tied into concussions and return to play protocols. The only thing I could find was in both the ’08 and ’12 Zurich statements they referred in the first step to aerobic activity at or below 70% of maximal heart rate. So I made that my starting point.
Just before the start of the school year I had several heart rate monitors donated to me. The Polar FT1’s I was given were very simple and easy to use. They had no fancy functions, but they provided heart rate that the athlete could see and try to control, as well as a record of the time of work out, average heart rate, and max heart rate for the workout, and I could set their target heart rate zone. I was now in a position to start using heart rate in my RTPP. Just two final steps remained, creating a working protocol, and getting permission to use it.
I went through several drafts before coming up with one that I submitted to my AD and our team doctor. New York States protocol had one more step then Zurich’s, and I ended up using the 70% HR for step 2, and so lowered step 1 and created a range of 60-65%, and step 2 65-70%, and each step increased by 5%. Everything looked good and I was ready to try it.
Unfortunately, I had athletes all too soon that had concussions and therefore needed to go through the RTPP. Everything worked well for the first couple of steps. The athletes were instructed to keep their heart rate in the correct zone. I told them the number range and programed the watch to beep at them when they were out of it. They were told that failure to remain in the proper zone could either have the workout stopped, and therefore nullified, if they went to high and they would have to try again the next day, and if they were too low, the workout would not count and they would also try again the next day.
The first step the athletes were initially limited to exercise bike and on second step running (treadmill or outside monitored), but I quickly opened up step one to a couple of other low impact aerobic machine we had (UBE, and rowing machine) and step two I included a couple of more and changed workout to at least 10min of running and then the rest of the workout could be on any of the machines (also have stepper and elliptical machines).
The heart rate monitors worked great for the first two steps. We caught one athlete pushing too hard and stopped them before any they could do themselves any harm and all others managed to keep themselves in the correct range. Problems didn’t start to arise until the remaining steps.
In step 3 the athletes return to sport specific activity. Unfortunately it is rare that this results in a consistent heart rate, so I had to amend protocol again. The athletes were instructed to keep their heart rates within prescribed range as much as possible, and to not go over it, but that they could drop below the zone as practice dictated. This wasn’t a big deal, but it meant my monitors were no longer as effective. I could check to make sure that the athletes didn’t push too hard, but there averages were now well below the zone and I had no way to judge how much time was spent at the effort level that they needed to test themselves at. I had no choice but to once again work somewhat in the blind. I used the max heart rate to keep the athletes under control and had to trust coaches and athletes that they were pushing hard enough.
I am in the process of ordering an upgraded heart rate monitor that will correct this problem. I’ve done some research and got a few recommendations and I am looking at getting the Polar RS300X. It has programmable zones and records how much time is spent in each zone. This is a bit of a bump up in cost, and will take more of a chunk of my budget, but from the results I’ve had so far with the FT1’s I think it will be worth it.
I also started finding that some of the athletes were having trouble staying within the heart rate parameters on step 2. Once they started going fast enough on treadmill to actually run they were over the top end of the limit and once they slowed heart rate down to proper range, it was too slow to run anymore. Upon further review of the Zurich consensus statement I decided that step 2 could be bumped up a notch, and every step thereafter, and still stay within their limited heart rate recommendations. So I increased every step by 5% and expanded the range on the last 2 steps.
Another problem that has very recently arisen is with wrestling. We have had some difficulty with the watches on step 5 being accidently stopped during wrestling, and they have caught on clothing. As a result, we are currently not using them with the wrestlers during contact activities on day 5 (also worried about athlete safety). I have found a couple of possible solutions to the problem, but need to research them further. One is that Polar makes a transmitter, wearlink+, which links with a device that can be plugged into a pc or laptop and record the data from a distance up to about 20 meters. They also make a Bluetooth transmitter that is compatible with newer iPads and iPhones. They even make an app for them that looks like it could open up interesting possibilities. Unfortunately I don’t have an iPhone or compatible iPad, so won’t be looking into that route for a while.
All of that being said, our RTPP is currently as follows:
Concussion Return to Play Protocol
Athlete must be symptom free for 24+ hours, fully return to ALL academic activities, pass ImPACT test and be cleared by School Medical Director before beginning this progression. No more than one (1) step may be done a day. If there is any return of symptoms, athlete must stop activity immediately, and be seen by school medical personnel, and after symptom free 24+ hours, may return to last symptom free step that they had done. The athletic trainers will monitor and control the athlete through the entire return to play protocol. Athlete must be seen by athletic trainer daily, before and after all activity including prior to start of Step/Day 6. Athletes will wear a heart rate monitor programmed by the athletic trainer for all five steps of the progression.
Step/Day #1: Low impact, non-strenuous, light activity – 20-25min on exercise bike (may also use rowing machine, or UBE) at 65-70% Maximum Heart Rate (HRmax).
Step/Day #2: Higher impact, higher exertion, moderate aerobic activity (running, stair stepper, elliptical, rowing machine, bike, &/or UBE), no resistance training – 25-35min (at least 10 minutes of which must be on treadmill or running) at 70-75% HRmax.
Step/Day #3: Sport specific non-contact activity. Low resistance weight training (must be able to do 12-15+ reps) with a spotter – 35-45min at 75-80% HRmax. HR may drop below 75% due to nature of practice, but can never be more than 80% and should spend part of practice in correct zone.
Step/Day #4: Sport specific activity, non-contact drill, higher resistance weight training (6-10 reps) with a spotter – 45-80min at 75-85% HRmax. HR may drop below 75% due to nature of practice, but can never be more than 85% and should spend part of practice in correct zone.
Step/Day #5: Full contact training drills and intense aerobic activity – 60-120min at 85+% HRmax. HR may drop below 85% due to nature of practice, but should spend part of practice in correct zone and must incorporate some maximal efforts such as repeat full speed sprints (4+ sprints of 50+ yards).
Step/Day #6: Return to full activities with clearance from School Medical Director.
As you can see, this progression stays right in line with the NYS protocol; it just adds a heart range for monitoring and control purposes. Notice I’ve also added in number of reps for weight training. I’m sure that this is something that will continue to be adjusted and changed with time and experience and as new research comes out. For now though, it is working well, but I’d love to get feedback on the RTPP from others. What are your thoughts on what I’m doing, good or bad? What are you doing to monitor and control your athletes through your RTPP? Do you know of any research that counters, or supports what I am doing? Thank you in advance. I’m looking forward to what everyone has to say.
I know that budgets can be tight, and heart rate monitors are an expensive luxury. However, when we are talking about the safety of our athletes, especially when dealing with concussions, the money is well spent. If the money doesn’t exist in the athletic training budget, athletic directors usually have discretionary money, as do principals and headmasters. If all else fails, parents associations are for the safety of their kids and can always find money for something as important as safety…