Music Progressive Return-to-Performance Protocol

Step 1

Exercise Strategy^a:

Engage in symptom-limited activity (light walking, reintroduction to school/work)

Recommendations:

• Avoid activities that increase symptoms, such as amplifiers, screens, excessive lighting, playing/singing with other performers, or carrying instruments around campus.
• Complete academic coursework as tolerated.

Step 2

Exercise Strategy:

Aerobic exercise (stationary cycling or walking), light resistance training^b

• 2A – light (up to 55% max heart rate), then
• 2B – moderate (up to 70% max heart rate)

Recommendations:

• Progress easy scales and etudes: 20 minutes of practice with 5-minute breaks.
• Gradual exposure to sound or music (no amplifiers).
• Progress aerobic activity and light resistance training for 10 to 15-minute increments up to 30 minutes.

Step 3^c

Exercise Strategy:

Individual discipline-specific exercise

Recommendations:

• Avoid activities with risk of head impact.
• Perform for up to 20 to 30 minutes during individual lessons with instructor.
• Increase aerobic activity for up to 30 to 60 minutes.
• Practice for 30 minutes individually with easy to moderate skill progression away from the music environment that may increase symptoms.
• Perform short songs to assess memory retention, with breath building from moderate to full performance tempo and intensity.
• Progress from warm-ups to familiar technical exercises and performing easy, familiar music.

Students may only progress through Steps 4-6 if they no longer report symptoms, altered cognitive function, or any other relevant clinical findings related to their current concussion, including both WITH and AFTER physical exertion.

Step 4

Exercise Strategy:

High intensity exercise with more challenging skills, reintegrate with other performers.

Recommendations:

• Increase duration and intensity of activity. Play pieces at faster tempo.
• Perform at 50-75% effort in lessons with 45-minute practice session per day (with rests as needed).
• Consider using a modified chamber/orchestra rehearsal. Use hearing protection with increasing sound if needed.
• Progress intensity and duration to 60-minute blocks with other musicians.
• Fully engage in class with the exception of playing or singing at high-pitched volumes and/or multiple percussion instruments.
• Full run-through with sheet music.

Step 5

Exercise Strategy:

Participate in typical training activities, reassess confidence and functional skills by performing arts faculty/staff.

Recommendations:

• Perform in usual music activities.
• Restore confidence and assess function by faculty or artistic director.
• Return to full class and rehearsals with no time or amplifier restrictions.
• Build endurance to typical intensity and duration with full costume, props, and/or instruments.

Step 6

Exercise Strategy:

Resume normal performance

Recommendations:

• Full rehearsal/performance activities without restrictions.

Source: Memmini AK, Hutchison O, Savvidou P, et al. Behind the curtain: Creating clinical guidelines to support university students returning to performance after concussion. Neurology. (Accepted). Table modified to meet federal accessibility standards. The original Progressive Return-to-Performance Protocol can be found from Neurology.

Note. The Progressive Return-to-Performance Protocol may serve as a framework for clinicians and/or university faculty/staff assisting students during their concussion recovery. The protocol provides specific examples unique to three performing arts disciplines (i.e., dance, music, and theatre performance) to safely progress students back to performance.

^aThe six-step progression is based on the recommendations proposed by the 6^th International Consensus on Concussion in Sport.¹ Based on their guidance, students may initiate Step 1 within 24 hours following injury, progressing through each step after a minimum of 24 hours. If symptoms increase during Steps 1-3, the student should immediately stop and try again the next day. Any students experiencing symptoms during Steps 4-6 should return to Step 3 to reduce symptom burden (especially before engaging in activities that increase risk for further head impact). Students are encouraged, if not required by their institutional policy, to obtain written documentation from an approved healthcare provider before they participate in unrestricted physical activity (Steps 4-6).¹

^bStudents may experience a mild or brief increase of symptoms (no more than 2 points on a 0 to 10-point scale) so long as it does not persist beyond 1 hour following physical exertion.¹

^cMedical clearance may be warranted in Step 3 if the student is engaging in any physical activity that puts them at risk for further head injury.¹

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