Tri-ValleyCentralSchool District

Return To Play (RTP) Protocol

Name:______D.O.I. ______Sport:______

Name of Student’s Treating Physician:______

Date of Visit______Date of Impact Post-injury exam: ______

____ CHECK HERE IF ATHLETE HAS BEEN ASYMPTOMATIC FOR AT LEAST 24 HRS PRIOR TO START OF RTP

____ CHECK HERE IF ATHLETE CAN BEGIN THE RTP PROTOCOL

School Medical Director Signature:______

Step 1. Light Aerobic ExerciseStart Date: ______Evaluator(Initials):______

Comments:______

Step 2. Moderate Aerobic ActivityStart Date: ______Evaluator:______

Comments:______

Step 3. Sport Specific Non-Contact Activity Start Date: ______Evaluator:______

Comments:______

Step 4.Sport Specific Activity, Non-Contact DrillsStart Date: ______Evaluator:______

Comments:______

Step 5.Intense Aerobic Activity, Full Contact Drills Start Date: ______Evaluator:______Comments:______

RTP Report Prepared by: ______Date: ______

Final Decision Rendered by District Medical Director______

Step 6. Return to PlayStart Date: ______Evaluator: ______

Comments:______

Return to Play Protocol

Implementation Procedure:

  • Student’s medical provider clears the student to begin a graduated return to activities, once student has been symptom free at rest for at least 24 hours.
  • District’s medical director clears the student to begin the Return to Play (“RTP”) Protocol.
  • Student retrieves RTP protocol from school nurse and gives to coach/physical education teacher.
  • Coach/physical education teacher observes the student and, immediately following each activity, reviews the RTP protocol with the student.
  • Coach/physical education teacher returns RTP protocol to the school nurse.
  • As long as there are no symptoms, the student can move forward to the next step the following day with school nurse approval.If any concussion symptoms recur, however, the student should drop back to the previous level then re-attempt the new activity after another 24 hours have passed.
  • The District’s medical director will use the RTP protocol to approve final clearance for return to play without restrictions. A student will not be allowed to fully return to play (game or competition) until final clearance has been received.

Step Progression:

Baseline (Step 0):The student has(1) completed physical and cognitive rest,(2) has not experienced concussion symptoms for a minimum of 24 hours, (3) has been cleared by his or her medical provider to begin a return to activities, and (4) has been cleared by the District’s medical director to begin to return to activities.

Step 1: Light Aerobic Exercise
The Goal: Increase in heart rate.
The Time: Approx. 20 minutes.
The Activities: Low-impact, non-strenuous, light aerobic activity such as walking or riding a stationary bicycle. Absolutely no weight lifting, jumping or hard running.

Step 2:Moderate Aerobic Activity

The Goal: Limited body and head movement.
The Time: Reduced from typical routine (at least 20 minutes).
The Activities: Higher-impact, higher exertion, and moderate aerobic activity such as moderate jogging, brief running, and jumping rope. Absolutely no resistance training.

Step 3:Sport Specific Non-Contact Activity
The Goal: More intense but non-contact activity.
The Time: Closer to Typical Routine.
The Activities: Non-contact sport-specific drills, and low resistance training with a spotter. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.

Step 4: Sport Specific Activity, Non-Contact Drills
The Goal: Reintegrate into practice without engaging in contact.

The Time:Typical Routine.

The Activities: More complex sport-specific training drills, and higher resistance weight training with a spotter.

Step 5:Intense Aerobic Activity, Full-Contact Drills
The Goal: Return to normal training activities.

The Time: Typical Routine.

The Activities: Full contact training drills and intense aerobic activity.

Step 6:Return to Play: Return to full activities without restrictions.