Safe return to play after protocol-based concussion management by a team therapist: a prospective study

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To analyse the safety of a multidisciplinary concussion management protocol where a team therapist is involved in return-to-play (RTP) decisions.


Prospective, pre- post-intervention cohort study over 4 seasons of competition


School-based American football program (4 teams; grades 8–12)


672 players x year (11–17 year old) for a total of 27741 athlete-exposure.


A protocol based on the Concussion In Sport Group recommendations was implemented. A computerised neuropsychological (CNP) test was used at baseline and prior to clearance for unrestricted training. For seasons 1–2, the protocol required the team physician to make all RTP decision while defined criteria allowed the team physiotherapist to make the vast majority of the RTP decisions over seasons 3–4.

Outcome measures

The primary outcome was the early recurrence (ER) of concussion symptoms following RTP (defined as during the same season).


A total of 119 concussions were identified (55 and 64 for the first and last 2 seasons, respectively; incidence rate 4, 3: 1000 athlete-exposures). At the time of the first clearance decision, the CNP test contributed to a negative RTP decision in 67% of cases. During seasons 1–2 no ER was observed. During season 3 one injury unrelated to football resulted in one case of ER prior to clearance and, during season 4, one case of ER occurred during the second game, 11 days after clearance.


Safe management of concussions was achieved whether the team physician or the team therapist was responsible for the application of the terms of the protocol.

Competing interests

Pierre Frémont chair of the Canadian Concussion Collaborative.

Competing interests

Édith Castonguay is the physiotherapist for the football program described in this study.

Competing interests

Francesco Pepe-Esposito is Head coach of the football program described in this study.

Competing interests


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