The Graduated Approach to Traumatic Brain Injury

Whenever discussions occur around traumatic brain injury, people typically think of boxing and football. The idea of a hit to the head comes to mind and many people still falsely believe that a brain injury must only have occurred if the athlete/person lost consciousness. So, let’s start this conversation with the definition of concussion to help clear up some things.


Back in April I reviewed the definition of a concussion. The definition is ever evolving, but the key take away is that the brain sustains damage both at a vascular and neurological level. The mechanical force causing the damage does not just have to be a direct contact, it can occur from torsional damage to tissue. This torsional type of damage is common in MVA accidents where whiplash is involved. In many causes there can be a long-standing vascular interruption that then affects how the neurons (brain cells) in the area or communicating with each other whether locally in the central nervous system or distally in the peripheral nervous system. This means a brain injury has the potential to also cause damage in our skeletal and digestive systems. This explains why there are so many varying symptoms! Now you can appreciate how being seen by a physician with proper training is imperative to proper and complete healing post-concussion.


Graduated Return to Play


This process is typically guided by a physician or trained athletic trainer. It involves a multi-step process to assure that the patient has healed enough from the concussion to be able to get back to competition. It begins with a concussion assessment, which at our office is the SCAT 5. This assessment determines the number of symptoms, severity of symptoms, cognitive testing such as memory testing, and some balance testing. This assessment is utilized to determine whether improvement is being met and at what rate. Our office also performs ocular and vestibular testing, which further aids with healing, but could be its own blog topic.


Below is a simplistic breakdown of a graduated return to play:


Key factor: There needs to be 24-48 hours of both physical and cognitive rest post-concussion.

Each step needs to be given 24 hours.

The athlete/person does not move onto the next step unless no symptoms occur in that 24 hours with the increase in activity.

If the athlete/person does experience a symptom within the 24 hours, they return to the step before.

Step 1: Symptom limited activity: Essentially the initial 24-48 hours

Step 2: Light aerobic exercise: Goal is to increase the heart rate. Involves walking or riding stationary bike at low to medium pace. NO RESISTANCE TRAINING.

Step 3: Sport-specific exercise: Running up and down court while dribbling ball (basketball), running around bases (baseball), running/sprinting drills (football). Goal is to add movement.

Step 4: Non-contact training drills: Progress to hard intensity cardio. In football and basketball in would now involve passing drills. Can incorporate resistance training.

Step 5: Full contact practice: participate in normal training activities.

Step 6: Return to play


There is a small percentage of athletes who will not be able to accomplish this graduated return to play within 7-10 days. In those cases, further referral or imaging would be ordered.

Keep in mind that the physician is also helping with a graduated return to school activities that will be touch on in a different blog


Please, please, please if your athlete sustains a concussion or you believe that they have, make an appointment with Function First Spine and Sport. Dr. Cindy has numerous hours in concussion diagnosis and treatment, as well as sideline experience. She follows best practices and believes in an integrative approach that promotes working with other health care providers.


Keep them safe and keep them moving!


Dr. Cindy

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