Navigating Return-to-Sport After Concussion: The 2023 Amsterdam Consensus Update

Hey colleagues, Let's talk about concussion, specifically getting our athletes back on the field safely. The game changed in 2023 with the release of the 6th International Consensus Statement on Concussion in Sport from Amsterdam. It builds on what we already know but gives us a more refined, evidence-backed framework for return-to-sport (RTS) decisions. As PTs, we are central to this process, and this new guidance empowers us to lead with confidence. **The New 6-Step Return-to-Sport Strategy** The biggest update is the evolution of the graduated RTS protocol. It's now a more detailed 6-step process, with each step taking a minimum of 24 hours. The core principle remains the same: gradual, symptom-limited progression. But the Amsterdam statement gives us more specific goalposts. Here’s the breakdown: * **Step 1: Symptom-Limited Activity:** This starts within 24-48 hours post-injury. We're talking about daily activities that don’t provoke symptoms. Think walking, light chores. The goal is to reintroduce activity without exacerbating symptoms, promoting recovery. * **Step 2: Light to Moderate Aerobic Exercise:** This is where we, as PTs, really start to guide the process. The protocol is now broken into 2A (light intensity, ~55% max HR) and 2B (moderate intensity, ~70% max HR). Stationary cycling or walking are great options here. We can introduce light resistance training, but the key is to avoid more than a “mild and brief” exacerbation of symptoms (no more than a 2-point increase on a 10-point scale, lasting less than an hour). * **Step 3: Individual Sport-Specific Exercise:** Now we add movement and change of direction. This means running drills, sport-specific movements, but still away from the team environment. It's crucial that any activity with a risk of head impact is avoided until medical clearance is given. * **Step 4: Non-Contact Training Drills:** The athlete can now integrate into team training, but in a non-contact capacity. This includes more complex and challenging drills like passing and multiplayer exercises. The goal is to resume usual exercise intensity and add cognitive load. * **Step 5: Full Contact Practice:** After medical clearance, the athlete can participate in normal training activities, including full contact. This step is about restoring confidence and allowing the coaching staff to assess functional skills. * **Step 6: Return to Sport:** Normal gameplay. **The PT’s Role: Objective Assessment is Key** Our value as PTs shines in the objective assessment of these patients. The Amsterdam consensus emphasizes moving beyond subjective symptom reporting. We have the tools to do this effectively. * **Vestibular/Ocular Motor Screening (VOMS):** This is a must-do. The VOMS is a brief screen that assesses vestibular and ocular motor impairments. It includes smooth pursuits, saccades, convergence, VOR, and visual motion sensitivity. Provocation of symptoms during the VOMS is a strong predictor of a prolonged recovery. A 2-point or greater increase in symptoms on any item is considered abnormal. * **Balance Error Scoring System (BESS):** The BESS remains a staple for assessing postural stability. It’s a quick and easy test to perform on the sideline or in the clinic. Remember to compare the score to the athlete’s baseline if you have one. An increase in errors from baseline can indicate a balance deficit. * **King-Devick (K-D) Test:** The K-D test is a rapid number naming test that assesses visual tracking and saccadic eye movements. A post-injury time that is significantly slower than the athlete’s baseline can be indicative of a concussion. By using these tools, we can identify specific deficits and tailor our treatment plans accordingly. For example, if a patient has a positive VOMS, we can implement a targeted vestibular rehabilitation program. If they have BESS deficits, we can focus on balance and proprioceptive training. **Patient Selection and Contraindications** This protocol is designed for athletes who have sustained a sport-related concussion. It’s important to rule out more severe injuries, such as cervical spine fractures or intracranial bleeding, before starting the RTS progression. Any athlete with red flag symptoms (e.g., worsening headache, repeated vomiting, seizures) should be immediately referred to the emergency department. **Putting It All Together** The 2023 Amsterdam Consensus Statement reinforces the importance of a multidisciplinary approach to concussion management, with PTs playing a vital role. By using the updated 6-step RTS protocol and incorporating objective assessment tools like the VOMS, BESS, and K-D test, we can make more informed and safer return-to-play decisions for our athletes. Let's embrace this evidence and continue to elevate our practice.