Improving Outcomes, Neurology, Pediatrics

Friday Night Lights: The Zurich Protocol

I practiced in an area where High School football was idolized.  Ask an EM provider what the guidelines are for returning to practice, and I think most respond, “until cleared by neurology.”  A recent study evaluated how frequently patients were given concussion specific discharge instructions and clear indications as to when to return to physical activity.  Frankly, the results are embarrassing.  Only 31% of patients received concussion specific instructions  and only 62% were given activity restrictions.

Here is a copy of my discharge instructions for the concussed, adapted from the Zurich protocol:

The Zurich protocol emphasizes both physical AND MENTAL rest. Physical rest means: no sports practice, no training of any sort, no exercise, no weight lifting, beware of exertion with activities of daily living (ie, household chores, walking up stairs, etc). Bottom line – keep your heart rate down. Brain rest means no television, no extensive reading, no video games, no computer games or social media, stay off the phone – no texting!, minimize daytime sleep, and consider taking time off from school and delay test taking if at all possible.

The graduated protocol is as follows:

Step 1: No activity- no physical activity (see above), and brain rest (again, see above)

Step 2: light aerobic exercise- walking, swimming, biking < 70% of maximum HR. no resistance training.

Step 3: sport specific exercise- ie, skating drills in hockey, running drills in soccer, NO HEAD IMPACT ACTIVITIES. Resume normal brain activities.

Step 4: non-contact training drills- progression to more complex training. ie, passing drills in football & hockey. May start progressive resistance training.

Step 5: Full contact practice: Following medical clearance may participate in normal training (must have PMD or neurology clearance to begin step 5).

Step 6: return to normal activity

*** DO NOT PASS STEP 1 UNTIL SYMPTOMS HAVE RESOLVED ***

*** IF AT ANY STEP SYMPTOMS RECUR, GO BACK TO THE PREVIOUS STEP *** 

All steps should last for 24 hours. If symptoms recur, go back a step for 24 hours. About 90% of patients are resolved within 7-10 days. Again, it is important to follow up with either neurology or your primary care provider within the week. Not doing so may result in a chronic or permanent injury, pain, and/or disability. If there is any problem keeping or making an appointment, you must call back to this facility for assistance. Tylenol is the only recommended medication in these scenarios. No ibuprofen, motrin, aleve, aspirin, or other NSAIDs. It is recommended AGAINST taking sleeping aids as it may mask or prolong symptoms.

Likewise, before the start of the school year, it may not be a bad idea to feel out PMDs & neurology to see how soon they could see these patients for follow up.

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http://m.bjsm.bmj.com/content/47/5/250.full

PMID: 24365726

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