Para concussion considerations for return to play
| Concussion suspected—remove athlete from play | Brief period of physical and cognitive rest | Gradual and progressive increase in activity while staying below their cognitive and physical exacerbation thresholds (activity should not worsen symptoms) | Graduated return to activities. Return to school should come before return to sport. | Return to school strategy: 1. activities at Home that do not produce symptoms, 2. School activities at home, 3. Return to school part time, 4. Return to school full time | Return to sport strategy: 1. symptom limited activity, 2. Light aerobic exercise, 3. Sport specific exercise, 4. Non-contact drills, 5. Return to sport | Management of persistent symptoms (symptoms which persist beyond 10–14 days in adults, or beyond 4 weeks in children) | |
| Impaired muscle power—spinal cord injury | No variation from standard management | For w/c users, physical rest may need to include considerations regarding manual w/c use and transfers | Mechanism for testing submaximal exercise challenge may need modification; balance testing and testing of reaction time may need to be augmented to accommodate baseline weakness and balance deficits | No variation from standard management | No variation from standard management | Mechanism for return to sport should be sport-specific and adapted to the individuals Para sport (ie, generic approach not appropriate) | Mechanism for implementing certain aspects of vestibular therapy requires augmentation for w/c users; Mechanism for implementing c-spine rehabilitation may require augmentation for those with h/o cervical SCI |
| Impaired muscle power - lower motor neuron | No variation from standard management | For w/c users, physical rest may need to include considerations regarding manual w/c use and transfers | Mechanism for testing submaximal exercise challenge may need modification; balance testing and testing of reaction time may need to be augmented to accommodate baseline weakness and balance deficits | No variation from standard management | No variation from standard management | Mechanism for return to sport should be sport-specific and adapted to the individuals Para sport (ie, generic approach not appropriate) | Mechanism for implementing certain aspects of vestibular therapy requires augmentation for w/c users; Mechanism for implementing certain aspects of vestibular therapy requires augmentation for those with h/o cervical SCI |
| Impaired passive range of movement | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some amputees. Balance testing or gait inspection might not be a reliable test to gauge return to training | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some amputees. Balance testing or gait inspection might not be a reliable test to gauge return to sport (unless the healthcare provider has a good understanding of baseline function) | Certain elements of balance training might require adaptation |
| Amputee/limb deficiency | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some amputees. Balance testing or gait inspection might not be a reliable test to gauge return to training | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some athletes with leg length difference. Balance testing or gait might not be a reliable test to gauge return to sport (unless the healthcare provider has a good sense of the gait pattern before injury) | Certain elements of balance training might require adaptation |
| Leg length difference | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some athletes with leg length difference. Balance testing or gait might not be a reliable test to gauge return to training | No variation from standard management | No variation from standard management | Cycling which is often used as a submaximal exercise challenge might not be possible in some athletes with leg length difference. Balance testing or gait might not be a reliable test to gauge return to sport (unless the healthcare provider has a good sense of the gait pattern before injury) | Certain elements of balance training might require adaptation |
| Short stature | No variation from standard management | No variation from standard management | No variation from standard management | No variation from standard management | No variation from standard management | No variation from standard management | No variation from standard management |
| Upper motor neuron conditions (stroke, TBI, CP) | No variation from standard management | Symptom threshold may differ for individuals with prior UMN conditions; for w/c users, physical rest may need to include considerations regarding manual w/c use and transfers | Symptom threshold may differ for individuals with prior UMN conditions; mechanism for testing submaximal exercise challenge may need modification; balance testing and testing of reaction time may need to be augmented to accommodate baseline weakness, increased tone and balance deficits | No variation from standard management | If applicable, previously existing academic accommodations should remain in place postconcussion to prevent unfamiliar changes to the academic environment (eg, smaller classroom environment for students with concentration difficulties due to TBI) | Symptom threshold may differ for individuals with prior UMN conditions; mechanism for return to sport should be sport-specific and adapted to the individuals' para sport (ie, generic approach not appropriate) | Mechanism for implementing certain aspects of vestibular therapy requires augmentation for w/c users and/or athletes with prior central neurological injury |
| Visual impairment | No variation from standard management | No variation from standard management | No variation from standard management | No variation from standard management | Possible increased cognitive exertion over sighted individuals | No variation from standard management; coordination with guide and education of guide may be needed | Athletes with VI may have reduced static balance15 and elements of vestibular rehabilitation and training may require adaptation; Individuals with reduced visual performance may have baseline chronic neck pain16 and thus elements of c-spine therapy may require adaptation |
| Intellectual impairment | No variation from standard management | No variation from standard management; may have difficulty with understanding instructions and compliance | No variation from standard management; may have difficulty with understanding instructions and compliance | No variation from standard management; may have difficulty with understanding instructions and compliance | Specific/unique strategies may be needed depending on degree of intellectual impairment and symptoms post-concussion | No variation from standard management; may have difficulty with understanding instructions and compliance | CBT can be performed in individuals with II but may need to be adapted17 18; may have difficulty with understanding instructions and compliance |
Green shading: no anticipated additional considerations for para athletes; yellow shading: potential additional considerations for some para athletes (dependent on the level or nature of athlete impairment).
CBT, cognitive–behavioural therapy; CP, cerebral palsy; h/o, history of; II, intellectual impairment; SCI, spinal cord injury; TBI, traumatic brain injury; UMN, upper motor neurone; w/c, wheelchair.