What is the Graduated Return to Play Protocol?

The Graduated Return to Play Protocol was first outlined in the Summary and agreement statement of the first International Conference on Concussion in Sport held in Vienna in 2001; it evolved and was clarified in each the three subsequent International Conferences in 2004, 2008 and 2012. The table below outlines the process.

GRTP Table

What does this mean for coaches during practice and competition?

The Consensus statement on concussion in sport, (Zurich 2012) states that young children do not lose consciousness as easily as teens and older children. They may not have the language to describe concussion symptoms they might be experiencing. Instead they may be more likely to complain of physical symptoms or act out behaviorally in response to their symptoms often complaining that they just “don’t feel good.” Recent preliminary research findings suggest that young children may need to take longer periods of rest following concussion. It is commonly recommended that they take at least an additional 7 day rest/recovery period after they are symptom-free.

The Model Policy contains the following protocol to follow when a concussion is suspected in interscholastic sports; the same protocol can be utilized in community-based sports:

1. Immediate removal from practice or competition. 911 should be called if there is a deterioration of symptoms, loss of consciousness, or direct neck pain associated with the injury.

a. This is YOUR CALL! It is important for you to learn to recognize the signs and symptoms of concussion.

2. Student-athlete should be evaluated by the school’s licensed healthcare provider who is trained in the evaluation and management of concussion.

a. Typically a community-based sports organization does not have a licensed healthcare provider available at practice or at a competition. Since there is no guidance in the Concussion Law or Model policy regarding who fills the role of the “school’s licensed healthcare provider…” this step in the protocol needs to be clarified by the sports organization when using school district fields. As a precaution a coach could insist that the player is evaluated by a physician before allowing the player back to practice or competition.

3. School personnel (Athletic Director, Building Administrator, Certified Athletic Trainer (ATC), School Nurse, Coach, etc.) next contacts parent/guardian and informs that a concussion is suspected.

a. A parent needs to be notified that an event occurred and a concussion may have been sustained. Considering that the coach is the responsible adult at the practice or competition it is apparent that it becomes the coaches’ responsibility to notify parents.

4. School provides student-athlete with district board of education approved suggestions for management/medical checklist to give to the parent/guardian, and physician or other licensed healthcare professional trained in the evaluation and management of concussion.

a. A Community-based sports group playing on school district property can request a copy of the district’s checklist to give to parents.

5. The student-athlete must receive written clearance from a physician, trained in the evaluation and management of concussions that states the student-athlete is asymptomatic at rest and may begin the district’s graduated return-to-play protocol. Medical clearance that is inconsistent with district, charter, and non-public school policy may not be accepted and such matters will be referred to the school/team physician.

a. The Model Policy states that the Graduated return-to-play Protocol should be monitored by a physician trained in the evaluation and management of concussion as well as the parents/guardians of the student-athlete. The graduated return-to-play protocol provides a measure of protection against the risk of second impact syndrome. The term second-impact syndrome describes an event that results in death or lifelong disability because an athlete sustains a second blow or hit before a concussion is completely resolved; the force of the hit does not seem to be significant to the onset of sudden impact syndrome. Research is ongoing to learn more about second impact syndrome as it seems to be something that only affects adolescents and young adults.

Whenever a concussion is suspected the first thing to do is to see a physician or other qualified healthcare professional knowledgeable in the identification, treatment and management of concussion. The Center for Disease Control and Prevention states that “Physicians can play a key role in helping to prevent a concussion and to improve a patient’s health outcomes through early diagnosis, management, and appropriate referral” and “Symptoms of a concussion may appear mild, but can lead to significant, life-long impairment affecting an individual’s ability to function physically, cognitively, and psychologically.” This is why it is so very important that coaches are well informed about concussion and know the signs and symptoms of concussion. There isn’t any one tool that can diagnose a concussion. Each concussion is unique because each individual is unique.

What to look for if a concussion is suspected: (Signs & Symptoms)

A concussion could be suspected because of the force of impact, because of where a student is hit, because a helmet became loose, or because of the student’s reaction to the hit; he didn’t get up immediately. Remember that you don’t need to be hit in the head to sustain a concussion; a hit to the body can transmit force to the head and cause a concussion.

It’s important to:

  1. Talk to the other players who may have observed the hit to get the details of the event. If you didn’t see the hit this information could be important for medical professionals to know. Even if you did see the hit it’s important to talk to the other players because they might be aware of some other detail that you don’t know about. For example teammates might know about a fall or car crash that happened the day before or on the week end.
  2. Do not remove a helmet on the playing field. Removing a player’s helmet off on the field could compromise treatment of a neck or spine injury.
  3. Look for signs of a concussion. Regardless of whether or not the player is reporting symptoms it is important that you know the following signs.

These are things you and other players on the field can observe:

  • Confusion/disoriented to time and place: Does the player appear to know where he is? Is he making sense when he speaks?
  • Dizzy or lightheaded/loss of balance: Once the player is upright is his gait normal for him? Does he seem to be leaning or losing his balance?
  • Foggy: Is the player repeatedly asking the same questions?
  • Glassy-eyed: Is the player focusing on you as you interact with him? Do his eyes look normal?
  • Slurred speech: Is there any indication that the player is having difficulty speaking?
  • Loss of consciousness: Does anyone on the field know if the player lost consciousness event for a few seconds?

Once you have determined that it is safe to move the student to the sideline it is important to:

  1. Take off the helmet. Because the player could become disoriented from a concussion it is easy for a player to assume that if his helmet is on it is ok to go back onto the field.
  2. Monitor every five or ten minutes for signs that the player is feeling worse or has more obvious signs of concussion. Is the player feeling better or worse?
  3. Use a sideline evaluation tool like the SCAT 3. The SCAT 3 is designed to be used by medical professionals; however,
    • there is a space on the form to record basic information about the player and the event. This information is important for clinicians to have when further evaluation is conducted.
    • There is also a place to track symptoms the player is experiencing; even if a medical professional is not available it is helpful to record early symptoms to provide this information to clinicians when further evaluation is conducted.
  4. a. Orientation: There are two sections of the SCAT 3 that provide information about how well oriented the player is to the immediate situation.

Below is a list of questions from the Maddox Questions and the Orientation sections of the SCAT 3 that can provide clinicians with important information:

  • What month is it?
  • What is the date today?
  • What is the day of the week?
  • What year is it?
  • What time is it right now? (within 1 hour)
  • At what venue are we at today?
  • Which half is it now?
  • Who scored last in this match?
  • What team did you play last week / game? Did your team win the last game?

Be sure to provide parents with all of the information you have collected for a player when a concussion may have occurred.

What else can coaches do?

  • Take a training course on concussion. The New Jersey Department of Education maintains a list of online courses.
  • Educate parents by distributing concussion materials as soon as you meet them so that they know what to expect from you in the event that you suspect a concussion may have occurred. (The Brain Injury Alliance of New Jersey provides free concussion tear off pads and other materials for coaches and parents. Visit our Publications page to learn more.)
  • Be prepared with fact sheets, forms and other documents to pass on to parents if a concussion is suspected.
  • Most importantly, take concussion seriously. Your knowledge about concussion has a direct impact on the decisions you make for players on the field.

Preventing Concussions

Currently there is no piece of equipment for preventing a concussion. Helmets are meant to prevent more severe brain injuries; although they stop the movement of the head, the brain continues to move which can cause a concussion injury. Headbands and mouth guards are also not proven to prevent concussion.

The best way to prevent concussion is to:

  • Always play by the rules for your sport; rules are established to keep player safe.
  • Always check equipment for proper fit and make sure players are not using damaged equipment.
  • Always practice good sportsmanship; coaches and parents set examples that players will follow. Good sportsmanship begins at the top!
  • Always follow Return to Play Protocol. Be sure that a player has been cleared to return to sports by a physician knowledgeable in the identification and management of concussion.
  • Always use proper technique for your sport. There are many changes being suggested by league organizations like learning to tackle without using your head. Research your sport and become informed about current recommendations and rules.
  • Never let your players play with symptoms!