Behind the Curtain

BACKGROUND AND OBJECTIVES: Performing artists are at risk of head injuries, such as falling from an elevated surface, partner stunting, collisions with other performers or equipment, and/or tripping because of low ambient lighting. However, contemporary clinical guidelines have not addressed the demands of university-level performing arts students. Furthermore, current return-to-learn strategies do not take into consideration the physical aspects of performance-specific skillsets. The purpose of this study was to develop consensus on appropriate postconcussion recommendations to support university-level performing arts students returning to dance, music, and theater performance. METHODS: Prospective panelists were recruited using targeted emails from May to June 2024, to participate in a study using the modified Delphi technique. During round 1 of the Delphi process, panelists responded to open-ended questions on how to adapt the International Concussion in Sport Group's 2022 return-to-sport strategy to address the needs of university performing arts students. The research team conducted constant comparative qualitative analysis to generate statements to be voted on during the subsequent rounds. In round 2, panelists anonymously rated each statement using a 9-point scale (1 = not at all important, 9 = very important). During round 3, panelists received the aggregate group scores with their individual scores from round 2 with the option to modify their responses if desired. Consensus was established if statements achieved average scores ≥7 after the final round. RESULTS: Twenty-one panelists (mean age = 41.9 ± 11.6 years; 71.4% female) enrolled in a 3-part Delphi study from May to December 2024. They included university-affiliated clinicians (n = 5), concussion researchers (n = 5), performing arts faculty/staff (n = 7), and students/alumni with concussion history during their university performing arts training (n = 4). Following the Delphi process, the panel agreed on 101 of the initial 189 statements (53.4%) resulting in the Progressive Return-to-Performance Protocol (PRTPP), a stepwise approach supporting safe return to dance (n = 26), music (n = 36), and theater performance (n = 39) after concussion. DISCUSSION: The recommendations generated herein include considerations for participating with other performers, using stage equipment/props, increasing performance endurance, and reintroducing environmental stimuli (e.g., costumes, lighting, amplifiers, or instruments). The proposed PRTPP serves as a framework to guide university-based medical and academic teams when developing individualized postconcussion management plans for performing arts students.