[Expert Physio Q&A] Return to play after concussion with Dr Brooke Patterson

This episode with Dr. Brooke Patterson is a snippet taken from our Practicals live Q&A sessions. Held monthly, these sessions give Practicals members the chance to ask their pressing questions and get direct answers from our expert presenters. In this episode Brooke discusses:

• Return to play outcome measures 
• Concussion prevention research 
• Brooke’s return to contact protocol (AFL)
• Prep-to-Play program 

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Dr. Brooke Patterson is an Australian Research Council Early Career Industry Research Fellow and physiotherapist who completed her PhD at La Trobe University. A former AFLW player with the Melbourne Football Club and later an Assistant Coach, Brooke went on to lead the development of Prep-to-Play, an injury prevention program for community women’s football. She now works closely with community coaches to implement effective knee and concussion injury prevention strategies. 

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Transcript

SPEAKER_02 0:05

There is some preliminary evidence from our prep to play trial, hopefully published this year sometime, that does reduce in concussion as well. And the more that teams use the program, the more in all injuries reduce. So that kind of dose response effect, which is good, but obviously they only work if you do them. So I do strongly believe that we need, especially in Australian football, and I think especially in juniors and especially in female women and girls who are already playing a little bit catch-up with some of these skills. That's the biggest area for like improvement is actually practicing the technique and getting them doing it training.

SPEAKER_01 0:43

Welcome to another expert QA episode. Today we're sharing a highlight from our recent session with Dr. Brooke Patterson, physiotherapist and research fellow at La Trobe University's Sport and Exercise Medicine Research Centre. Brooke's postdoctoral work focuses on reducing knee injuries and concussion in women's AFL, and she played a leading role in developing the Prep to Play Injury Prevention Programme. In this episode, Brooke unpacks the crucial topic of return to contact after concussion, drawing on both research and clinical experience. You'll hear key insights into prevention, management, and how she safely guides athletes back to contact sport. Remember, practical subscribers get live access to these Q ⁇ A's with experts like Brooke, plus the chance to ask their own questions. We hope you enjoy the conversation.

SPEAKER_00 1:35

Hi everyone, my name's Sarah, and I help run the QAs for Physio Network. And I'd like to start by welcoming Brooke, who is here tonight to answer some of the questions that have been submitted about her fantastic practical. So welcome to you, Brooke, and thanks again. And I hope you all enjoy the session. And we might kick start with our first question, which is do you retest SCAT or other outcome measures during the return to play process?

SPEAKER_02 2:05

That's a great question. And not usually. So the SCUT has kind of limited utility as like a return to play tool beyond that kind of acute phase, like really within the first seven days. So it's a tool, and this is advice from the like international consensus statement on sports-related concussion. So the SCUT's like really good at discriminating between people that are cancast and non-concast in that first semi-two hours. But a lot of the tests actually have ceiling effects. And unless you actually have like a baseline test of that athlete, which might be, you know, you might have that in the elite setting, but in in a lot of settings, you might not have that. So you don't actually know like what is normal for some of those tests. So it's a little bit tricky to use. I guess the main thing at that return to play, you know, what you're reassessing is that they're symptom-free. So the scat might be helpful in terms of just refreshing yourself of those potential symptoms that they initially presented with and making sure that those things are not still there and maybe probing about some of those things. Yeah, the main thing is that they actually can just progress through their activities that they need for sport and the graded return, you know, symptom-free. And these are kind of really our best tests at that end stage.

SPEAKER_00 3:20

Just on that, any other outcome measures that you would retest in that return to play process?

SPEAKER_02 3:26

I would be making it very sport-specific in terms of them hitting their like intensity of their training, but also kind of, I guess, if the training isn't designed to kind of really test them out for those game-like scenarios that you might need to be a little bit more prescriptive in really challenging them physically, but also cognitively and throwing in a few different kind of complex drills and tasks.

SPEAKER_00 3:50

All right. Question number two do you include any next specific strength or exercises when working with athletes post-concussion?

SPEAKER_02 3:59

Uh, I thought this always comes up with the topic of concussion, I think. So maybe if I start with the evidence for neck strength and also neck strengthening as an intervention, and then going to maybe some clinical kind of recommendations based on that evidence. So the evidence for neck strength as a risk factor for, say, head impacts and concussion is very mixed. So there's a a handful of studies that would show an association. If you have weaker neck muscles, you're at an increased risk of having a head impact or a concussion. And then there's also a handful, handful of studies that show that there's no association there. And as the listeners might appreciate, these studies are very difficult to conduct. You need a large sample, you need then people to go on to have the head impact or injury. And there's so many confounding factors like previous injury, the type of sport. So very tricky to know whether it's an important factor that we can modify to prevent concussion. You know, theoretically, it's plausible that if you have good strength and control of the neck, those muscles do play a key role in stabilizing the head and resisting those linear and rotational accelerations. So I think theoretically that it's there, but we need a little bit more research. In terms of the evidence for neck strengthening, so for all in like all injuries, risk factor studies are like so hard to do. And actually, we just go and do the intervention and test that and see if it works, is sometimes the best way to kind of get to the answer. Again, there's pretty conflicting results there for the effect of neck strengthening. So there's lots of studies that have say added neck strengthening to the FIFA 11 plus. A lot of studies in in soccer also doing like heading training, so a little bit more kind of sport-specific, kind of neck control. Again, a handful of studies show it's effective, a handful that haven't shown any effect. And these the exercises in these trials and kind of pilot, some of them are more pilot studies and not randomized controlled trials either. They are either kind of isometric holds of the neck, some of them are more like dynamic exercises, like kind of falling and rolling backwards and controlling the neck. There has been a couple of studies that show, like, if you do neck strengthening, obviously your neck gets stronger, and also that it does do a better job of resisting some of those acceleration events, but not really that many have shown does it then go to the next step of preventing concussion. So I know that probably doesn't help the listeners very much to say that there's no evidence or I'm I'm very much sitting on the fence because the evidence is sitting on the fence. But you know, if we take that into account, there's clearly something there. What would be the like I guess clinical recommendation from that? Anecdotally, I know a lot of elite programs, especially in those contact codes, are doing neck strengthening. You know, it can be from isometric to more isotonic fast slow strength movements plus some reactive strength. So I think it definitely is a consideration, and certainly there's nothing, I don't think, lost in in doing it. If it's something you're considering, I'm not aware of any kind of adverse events from any of these studies. Of course, if you do anything a little bit too the hard or challenging, you might get sore from it. You know, the only thing that's probably lost is time, and especially in community sport where, you know, we even struggle to get a neuromuscular training warm-up implemented, and then you're getting them to do kind of static neck holds and things, it's it's a challenge with the implementation piece, I think. So I think we probably need a little bit more evidence to be going and saying to particularly community sports teams, you need to be doing neck strengthening for concussion. Especially because a lot of the good strengthening does require a little bit of like equipment setup as well. There has been in community male rugby, a neuromuscular training program, where they do a little bit of kind of core strengthening that's very specific to like the scrum positioning, kind of four-point yields and holds and things like that, that has been shown to reduce concussion rate. So there's only one study in kind of that youth male rugby that has shown that. So there's potentially some of the other elements of the new muscular training programs that might help prevent concussion, whether that's just the general core strength, plus some of the spatial awareness and body awareness and balance and things like that.

SPEAKER_01 8:18

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SPEAKER_00 8:43

The next question is can you please talk about the pre-contact phase? So where the athlete is returning to general aerobic exercise. And what are the guidelines and how would you structure it?

SPEAKER_02 8:54

Yeah, so this is very specific to the particular protocol. So I will just say for anyone listening in, look up your own, like the sport that you're dealing with and their protocol because they outdo or slightly differ a little bit. And if you don't, if there's no kind of sport-specific guideline, then you kind of then your next best option is going to kind of the you know Australian Sports Commission or more general guidelines from say Sports Members in Australia or the APA and things like that for a little bit of guidance. But they're all within the same, you know, realm of those progressions. This is the AFL graded return to play. So stage one in this protocol is relative rest. So if the injury happens on a Saturday at footy, you know, definitely the rest of the day, the next day, potentially even the Monday, it's gentle day-to-day activities. So minimising that screen time. So that might mean a day off school and minimizing phone time on the Sunday and Monday, and yeah, taking it fairly easy. Some short walks would be fine. And then they can progress after one to two, two days of that. So there's kind of no more sitting at home for a week, a week off school, laying in bed for a week. The evidence would suggest actually kind of getting moving as long as symptoms are not worsening. So they can have some kind of mild symptoms in this next recovery phase. So as long as when they do their, you know, this next activity that their concussive symptoms don't really increase more than kind of a two out of ten from what it was previously. And if it does, then they kind of have to stay at that phase. So if yeah, the injury was on the Saturday rest day on the Monday, short walks, and then you know, they might come along to training, then on the Tuesday, and this is where they can go into their light aerobic phase. So max heart rate of 120, no skills, and it might be just either a walk jog or a bike, one minute on, one minute off for 20 minutes. For most kind of community athletes, that would be something suitable. They can come along, walk around, watch training for a little bit, and then probably not hang around for the whole night, head home and and rest up. And then the next would be so if they get through that okay, then they can go to that moderate aerobic and they have to spend at least two days in this moderate aerobic stage. You know, they might not be coming along to training, so it might be prescribing them something that they can do on their own, like a moderate intensity bike session or bike ride where they can go up to that, you know, 60 to 80% maximum heart rate. And then I've just got a suggestion here. So five times one minute on, two minutes off, or like a 15-minute steady. So if they're doing two days of moderate aerobic, one of them I would say a bike, and then the other one I would do get them to do some kind of run through. So this would just be an example, five two hundreds at six to eighty percent, and doing two sets of that, and then doing two five minute runs, keeping that heart rate in that range. All going well. If their symptoms, you know, haven't gone back, haven't worsened. This is just an example case study here. They've got their headaches completely, you know, they had a five out of ten, then it was a two out of ten when they did their light aerobic, but stayed two out of ten in the moderate aerobic, which is okay. And then that kind of disappeared from then on. So then the high aerobic, they can start doing a bit of um moderate intensity gym, but around up to 70% of their usual weight. And then a run might be up to max heart rate now. So that has to be athlete appropriate. You know, this was I was speaking to a group of kind of community junior senior footballers, so it's kind of around four to five kilometres for a training session, some intervals plus some volume, make it kind of specific to what they would normally cover in a training session. And then, you know, give them a bit of a rest. This is when they're entering into that stage three. So if I just go back to this, once they get to the end of this recovery period, they do have to have those complete symptoms gone, remember. So yeah, it has to be zero out of ten for all of their symptoms before they even can do non-contact training. So that's this phase now. So they can keep doing their gym and progressing up to their normal resistance and then coming into non-contact skills and drills and their run program for their first session back. Maybe a gym or some cross-training would be a rest, and then another session of the non-contact drills, the same as, and then it's a week of this. So minimum seven days for this is for the AFL program, they have to be in just right at the bottom here. They have to be in non-contact training for a minimum of seven days. And then this is that final phase where they're going to some limited contact drills. They need to have that review and clearance for their return to full contact training from a medical practitioner, then they can go into full contact training and return to play on day 21. So this limited contact is a is a quite AFL specific. A lot of the other protocols don't have that. What that means is some of those things I was showing in the the practical. So not going into competitive 3v3 games, it's it's more, you know, introducing to like one-on-one contact either with like a coach or a physio or a peer, whether that was some some tackling or some competitive ground balls or competitive aerial balls or whatever the sport might be. So just kind of in a controlled manner to see how they respond to that, you know, initial contact before they're going into the really competitive stuff. Hopefully that helps lay it out.

SPEAKER_00 14:23

We've sort of touched a little bit on this, but the last question is is there evidence to suggest that programs such as the one demonstrated in your practical do actually reduce further concussions?

SPEAKER_02 14:34

Great question. And yeah, I think I kind of mentioned that the only actual published study that's shown to reduce concussions from a neuromuscular training warm warm-up program is in community youth boys rugby. So, yeah, a study by Hugh Slot and colleagues. It's the Activate program. So if you look up the Rugby Activate, it's all on the World Rugby page. You can see some of their exercises, but they're very similar to kind of and we base prep to play on that that program and and others like the 11 Plus and you know other programs in Canadian basketball, rugby as well, volleyball. So only one study, but there is some preliminary evidence from our prep to play trial, hopefully published this year sometime, that does reduce in concussion as well. And the more that teams use the program, the more in all injuries reduce. So that kind of dose response effect, which is good, um, but obviously they only work if you do them. So we still don't know what the critical kind of elements are or what the dosage is required. But I think definitely getting them doing, you know, high fidelity exercise, neuromuscular training exercises. I think the contact elements of prep to play were probably where we had the biggest change in coach behaviour. So there's a lot of fear from coaches and players and parents that, you know, we don't want to do these things at training because of the risk. So actually, what if a lot of our program was actually more empowering and showing them safe ways to do it in a controlled manner and then build up from there? And that's actually where we had the biggest buy-in from the program and uptake of the program because it's, you know, they're footy drills as well. So it was a little bit easier to sell than you know neuromuscular warm-up and strength at the end of training. So I do strongly believe that we need, especially in Australian football, and I think especially in juniors and especially in female women and girls who are already playing a little bit catch up with some of these skills. That's the biggest area for like improvement is actually practicing the technique and getting them doing it training, as opposed to probably what we hear out of the NFL and American football, and that where the sports just it's all that collision, contact tackling. So I get that in those sports there they've got some guidelines and rules around, and there is some evidence in American football where they've reduced the contact load in train and that reducing the risk of you know concussions in training and in games. But I think it's a completely different sport and context, and actually in most other sports like Australian football and heading's a whole nother, you probably should get heading in for um whether we should be banging heading or actually training heading in a controlled manner. Yeah, same kind of concept, I think.

SPEAKER_00 17:10

Brooke, that was very helpful this evening, and thank you to everyone that has joined tonight. And this will also be uploaded so you can also listen to the recording later on.

SPEAKER_02 17:20

Thanks very much for jumping on, everyone. Enjoy the rest of your night.