Phase 1 may include LIGHT aerobic activity. J Athl Tr. This process, developed from internationally accepted guidelines, ensures that each player receives consistent treatment. The Six Pillars of Concussion Risk Management, Reducing Concussion Risk & Repetitive Head Impacts, Return to Learn and Play after Concussion, Effects of Concussion & Repetitive Head Impacts, Effects of Concussion and Repetitive Head Impacts, International Safeguards for Children In Sport, self-reporting by athletes of signs and symptoms, only a small subset of their potential symptoms when reporting their recovery. 2009:23(11):888-98. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines. KHSAA Concussion Return to Play Protocol Return to play policy for a student-athlete receiving a concussion, after the mandatory removal that day a) Once a concussion has been diagnosed (or presumed by lack of examination by an appropriate health care . The INC will be consulted specifically to answer the question of the player-patient's neurological health and his full return to competitive participation (see Phase 5 below). Recovery time will vary from player to player. Goforth M Jr. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. This involves three basic steps: Notably, imaging techniques, such as magnetic resonance imaging (MRI), may be used in more severe cases, when bleeding in the brain is suspected. Each player and each concussion is unique, and there is no set time-frame for return to participation. CDC twenty four seven. The authors suggested three possible reasons: A 2013 studyof concussed student-athletes who reported nosymptomsand had returned to baseline oncomputerized neurocognitive teststaken before beginning thegraduated return to sports protocol,found that more than a quarter (27.7%) exhibited declines in verbal and visual memory on the tests after moderate exercise. There is no set time for a concussion protocol as every injury is different. However, the NFL protocol includes additional stipulations and recommendations. a Giant, The One Flag Tournaments & An NFL player immediately goes into the concussion protocol the moment there is an on-field concussion or a concussion is suspected. Evaluation. "On game day, it's all about everybody being on the same page," he said, "just like players and coaches are on the same page because they practice. "The player's health and safety is the most important thing, and we're educating each other in sessions like this so that we can give the player the best care possible," he said. They help us to know which pages are the most and least popular and see how visitors move around the site. Football, For SportsRelated Concussion in Children and Adolescents, Resistance exercise, theValsalva maneuver, and cerebrovascular transmural pressure, Return to play after a concussion principles and practice, Compliance with return to play guidelines following concussion in US high school athletes, 20052008, Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review, High school rugby players' understanding of concussion and return to play guidelines, Concussion in the pediatric and adolescent population: Different population, different concerns, American Medical Society for Sports Medicine position statement: concussion in sport, Doolan AW Upcoming & OnDemand, Insurance Increasing football specific demands to determine if there is any aggravation concussion signs or symptoms. If neurocognitive testing was not administered after Phase Two, it should be administered during Phase Three. Connect with Texas Children's Hospital on our social media channels, Gastroenterology, Hepatology and Nutrition, Gastroenterology, Hepatology and Nutrition (RESEARCH), Financial conflicts of interest in research. & Training, Youth Tackling & Contact A concussion protocol is a set of guidelines and tools for the treatment and management of a concussion. Methodology In order to assess the implementation of Return to Play laws, the National Center for Injury Prevention and Control (NCIPC) conducted a case study evaluation on the Return to Play implementation efforts in two states: Washington and Massachusetts. Contact, Athlete The guideline was written by a group of authors that included Dr. Robert Cantu, a senior adviser to the NFL's Head . In 2018, the NFL is holding three medical trainings in Los Angeles, New Orleans and Chicago, and the league has expanded the number of attendees to include all Team Physicians, Athletic Trainers, booth ATC spotters, Unaffiliated Neurotrauma Consultants (UNC), Independent Neurological Consultants (INC) and neuropsychologists. You can review and change the way we collect information below. Managing return to activities. It provides the tools healthcare providers need to decide when it is safe for someone who has experienced a concussion to return to activity. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. After having been diagnosed with a concussion, the player-patient must progress through the following protocol to return to participation. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Each Club must designate at least one INC at the start of the League Year, which must be approved by the NFL Chief Medical Officer and NFLPA Medical Director. This website made possibilewith the MindMatters grant. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. After a concussion, an athlete should only return to sports practices with the approval and under the supervision of their health care provider. Progress is monitored at every stage, with healthcare providers clearing patients for more activity once theyre certain its safe. The .gov means its official. The team names, logos and uniform designs are registered trademarks of the teams indicated. "Tua is home and initial tests were negative," a Dolphins spokesperson said, and the quarterback tweeted that he was "feeling much better.". Returning to Play (Sports and Recreation) When to Refer to a Specialist CDC Expert Commentary Video on Returning to Play Related Pages and Resources Online Concussion Training for Health Care Providers Concussion Signs and Symptoms Returning to Sports and Activities Returning to School FAQs about Baseline Testing NFL and the NFL shield design are registered trademarks of the National Football League. The team names, logos and uniform designs are registered trademarks of the teams indicated. 2013;45(6):1023-1029. KHSAA Form GE80 Rev 7/17 . American Association of Neurological Surgeons. Hollis SJ Regular monitoring of progress is required. Meehan W, dHemecourt P, Comstock D. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Multiple authors have described that those who have suffered a prior injury have up to a 5.8 fold increased rate of reinjury.613 Therefore, treating an athlete with multiple concussions involves emphasizing the need to consider the longterm consequences and recovery prior to RTP.2527. Objective We compared data from the National Collegiate Athletic Association (NCAA) Concussion Study (1999-2001) and the NCAA-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium (2014-2017) to examine how clinical management, return to play (RTP) and risk of repeat concussion in collegiate football players have changed over the past 15 years. Do You Know The Signs and Symptoms of Concussion? Thank you, {{form.email}}, for signing up. The site is secure. Med. A pediatric or adolescent athlete should begin the RTP progression once they have achieved a full return to school (cognitive activities). You will be subject to the destination website's privacy policy when you follow the link. Once an athlete is asymptomatic, graduated return to play (RTP) protocol can be initiated. The steps in which a player can return to play -the protocol wasamended in July 2020 -are outlined here. Concussions are serious injuries and can remove athletes from competition for significant stretches. Virtual visit appointments available 7 days a week from 9:00am to 11:00pm. (The student-athlete's progress may be reviewed electronically or by phone and does not require an A concussion is a rare but potentially serious injury of football players. If the consultant agrees with the club physician that the players concussion has been resolved,then the player can participate in practice and contact without restriction. For the avoidance of doubt, if a player-patient cannot participate in practice or full contact with other players due to the time of year and/or rules imposed by the Collective Bargaining Agreement, simulated contact activity will suffice to satisfy this Phase. In 2010, the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. Strenuous cardiovascular challenge to determine if there are any recurrent concussion signs or symptoms. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed these sequential sportsspecific RTP guidelines. 4. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. Adherence to even the current general return to play recommendations continues to be a challenge in the pediatric and adolescent sporting community. Information for Parents, Coaches, and School & Sports Professionals. Full participation in practice and contact without restriction. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking, regular weightlifting routine, non-contact sport-specific drills (in 3 planes of movement). Checks, All Resources The intention was to maintain the integrity of the current 6step basic progression suggested by the ICCS and adopted by the AAP, spanning the time period from no physical activity to full RTP. While these policy efforts show some promise, more research is needed to learn if these strategies can help educate coaches and parents about this issue and help protect children and teens from concussion and other serious brain injuries. These two states were selected because they were both early adopters of Return to Play and because their laws varied on several important dimensions, including the role of the health department and other stakeholder groups. We apologize for any inconvenience that this may cause. Howell D, Osternig L, Van Donkelaar P, Mayer U, Chou L. Effects of Concussion on Attention and Executive Function in Adolescents. Team medical staff or neurology specialists must immediately assess symptoms, with a follow-up evaluation stipulated 24 hours after the injury. 5. If there is any increase or aggravation of signs or symptoms, the activity should be discontinued. If an athlete develops symptoms the progression should be stopped and the athlete must be returned to the previous phase. 20122013 high school athletics participation survey, The epidemiology and impact of traumatic brain injury: a brief overview, Subacute symptoms of sportsrealted concussion: outpatient management and return to play, Effects of a symptom free waiting periods on clinical outcome and risk of reinjury after sportrelated concussion, Incidence and risk factors for concussion in high school athletes, North Carolina, 19961999, The role of concussion history and gender in recovery from soccerrelated concussion, Risk of injury associated with bodychecking experience among youth hockey players. Consensus statement on concussion in sportthe 5th international conference on concussion in sport held in Berlin, October 2016. Excellence Program, Limited Added a third UNC who will monitor the broadcast video and audio feeds of each game from the spotters' booth, and notify on-field UNCs of possible head, neck or spine injuries. Ford MA Only allow the athlete to return to participation after he or she is cleared by an appropriate health care professional and institute your programs return-to-play procedure. The player-patient should not proceed to contact activities until their neurocognitive testing is interpreted as back to their baseline level by the NPC or, if a decrement is still present, until the Club physician has determined a non-concussion related cause. That hasnt changed during the pandemic, just expanded to mean more. An Example of a Graduated Exertion Protocol* #. A prospective cohort study, Summary and agreement statement of the first international conference on concussion in sport, Vienna 2001, Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004, Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008, Consensus statement on Concussion in SportThe 4th International Conference on Concussion in Sport held in Zurich, November 2012. Padua DA, et al. 2008;43:265-274. 1 Remove athlete from play. Because they have more training and experience in concussion diagnosis and management,certified athletic trainers, team doctors, and neuropsychologists are usually the best qualified to decide when it is safe for an athlete to return to play. Table 1. Incidence, risk, and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players, Does the apolipoprotein epsilon 4 allele predispose varsity athletes to concussion?. Neurocognitive testing can be introduced any time after completing Phase Two (see below) and prior to the initiation of contact activities. The guide presents considerations, as well as lessons learned from state stakeholders and potential barriers to implementation, in the following areas: To receive email updates about this topic, enter your email address: We take your privacy seriously. Am. ", National Football League Head, Neck and Spine Committee's Protocols Regarding Return to Participation Following Concussion. All other NFL-related trademarks are trademarks of the National Football League. the team Athletic Trainer, booth ATC spotter, team Physician, NFL game official, coach, teammate, sideline Unaffiliated Neurotrauma Consultant (UNC) or booth UNC initiates the protocol. However, if an official licensed athletic trainer or other official . To provide you the richest and safest experience, & Training, Youth Tackling & Contact Once a player is feared to have a head injury, they're mandated to be taken off the field of play immediately and examined in a medical tent to assess the injury. 7. Required all players who undergo any concussion evaluation on game day to have a follow-up evaluation conducted the following day by a member of the medical staff. Checks, All Resources Given the unreliable nature of self-reported symptoms in athletes, Our thinking, said McGrath, is that since exercise is known to cause recurrence of symptoms in some athletes who may not be fully recovered, and since neurocognitive testing has been shown to revealpersisting cognitive deficits in athletes who say or feel that they are symptom-free, Test Your Concussion Knowledge, Awareness, Attitudes, And Behaviors. sharing sensitive information, make sure youre on a federal Guskiewicz KM To receive email updates about this topic, enter your email address: We take your privacy seriously. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (less time and/or less weight from their typical routine). We went back and forth on this plan with several doctors and football experts to make sure we got it right. 1 Concussion protocols are established by organizations like the Centers for Disease Control (CDC) and sports leagues like the National Football League (NFL). In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed several sportsspecific RTP guidelines. The National Football League's concussion protocol is again in the spotlight after Miami Dolphins quarterbackTua Tagovailoa was injured duringThursday night's game against the Cincinnati Bengals. In order to assess the implementation of Return to Play laws, the National Center for Injury Prevention and Control (NCIPC) conducted a case study evaluation on the Return to Play implementation efforts in two states: Washington and Massachusetts. 8600 Rockville Pike National Federation of State High School Associations. Championship, Virtual Engagements: Call 911 if you experience any of the following: A concussion protocol is a set of policies and procedures for treating someone with a concussion. These activities will provide sports specific challenges to each athlete while simultaneously accomplishing the objectives of each stage of the RTP progression. Diagnosis typically occurs in the emergency room setting or on the athletic field following the fall or head impact. The Washington law was the first state law to require a removal and clearance for Return to Play among youth athletes. For clarity; all signs, symptoms, and neurological examination (including neurocognitive testing and balance testing) must return to baseline status before returning to full football activity/clearance. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Each organization may have a slightly different concussion protocol based on the type of facility, available medical equipment, and on-staff specialists. By Mark Gurarie As a library, NLM provides access to scientific literature. The following sports specific RTP criteria developed by a multidisciplinary sports medicine team at Children's Healthcare of Atlanta was written and implemented into the Atlanta, GA metro service area in 2012 (Appendices 110). The post-injury neurocognitive testing must include a focused, face-to-face clinical interview and the designated NFL paper and pencil test battery(AttachmentB),andifdoneatbaseline, thecomputerized neurocognitive test. Weill Cornell Brain and Spine Center. An age appropriate physical, cognitive testing and symptom checklist is recommended as a component of the assessment as patients below age 13 tend to report concussion symptoms different from adults.17 Consensus in the literature is that those who manage a younger athlete with a concussion should be prepared to extend the recovery timeline.17,24 The extended time is a product of the different physiological response that children and adolescents demonstrate as a result of a concussion (e.g. An athlete should only move to the next step if they do not have any new symptoms at the current step. Duration and intensity of the aerobic exercise can be gradually increased over time if no aggravation of symptoms or signs return during or after the exercise. While many of the youth sports concussion safety laws passed by the states since 2009contain broad language allowing any qualified healthcare professional to make the return-to-play decision, studies show thatmany primary care physicians(10)lack the expertise required to make return to play decisions. He may, however, attend regular team meetings and engage in film study. Add the cognitive engaging in football drills. Routine daily activities as tolerated, with the introduction of light aerobic activity (e.g., 10 minutes on a stationary bike or treadmill with light to resistance supervised by the teams athletic trainer. The player-patient may continue cardiovascular conditioning, strength and balance training, team-based sport-specific exercise, and participate in non-contact football activities such as throwing, catching, running and other position-specific activities, progressing to participation in non-contact team practice activities. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions. Each player and each concussion is unique. Can`t recall events prior to or after the hit or fall. Left guard Jonah Jackson did not practice Tuesday for a second straight day and is unlikely to play Thursday because of a brain injury. OPINION:Tagovailoa's second distressing injury in four days is ugly moment for NFL, NFL NEWSLETTER:Sign up now to get exclusive content in your inbox. Now all 50 states have a Return to Play law. During this Phase, the player-patient may engage in activities of daily living as well as limited stretching and balance activities as tolerated at the discretion of the Club medical staff. Parents, Coach The following browsers are supported: Chrome, Edge (v80 and later), Firefox and Safari. Thank you for taking the time to confirm your preferences. No head impact activities, Progression to harder training drills, e.g. Pediatrics2010;126(3):597-615. This season will be different than any other in history. the player exhibits or reports symptoms or signs suggestive of a concussion or stinger (a nerve pinch injury); or. Keith H. May, PT, DPT, SCS, ATC, CSCS, Clinical Outcomes Project Manager Sports, Medicine Program, Children's Healthcare of Atlanta, 5445 Meridian Mark Rd. Remember, this is a gradual process. Return to Physical Activity Following ConcussionCheerleading, Return to Physical Activity Following ConcussionGymnastics, Return to Physical Activity Following Concussion Football, *Start w/o helmet; progress to helmet and shoulder pads if symptom free. Despite these improvements in the care of athletes, there continues to be a lot of confusion among athletes, parents, and coaches as to the proper management of a concussion, particularly those that occur in children. 6-Step Return to Play Progression For athletes, the protocol can be broken into six stages, following an initial rest period of 28 to 72 hours: Due to high numbers of traumatic brain injury among active and retired professional football players, the NFL established a concussion protocol in 2009, and its since been updated several times. Introduction of strength training supervised by the athletic trainer. The concussion recently suffered . All steps of Return to Play Plan have been completed successfully. The authors propose adding a moderate activity step highlighted by resistance training and modifying steps three and four to include noncontact and limited contact drills specific to the athlete's sport. If a player-patient's initial neurocognitive testing is not interpreted as back to baseline by the NPC, the tests will be repeated at a time interval agreed upon by the Club physician and NPC (typically 48 hours). Beaumont. The NFL's Intensive Protocol evolved throughout the 2020 season based on ongoing analysis of extensive testing and contact tracing data. Heads Up Football is a comprehensive program developed by USA Football to advance player safety in the game of football. Daily activities that do not provoke symptoms, Gradual reintroduction of work/school activities, Walking or stationary cycling at slow to medium pace. Guskiewicz KM Return to play should not be allowed until all symptoms are absent, the athlete has completed a sixphase returntoplay protocol, and has been cleared by a healthcare professional with experience managing concussions. In order to assess the implementation of Return to Play laws, the National Center for Injury Prevention and Control (NCIPC) conducted a case study evaluation on the Return to Play implementation efforts in two states: Washington and Massachusetts. Amended July 2020 National Football League Head, Neck and Spine Committee's Protocols Regarding Return to Participation Following Concussion Return-to-Participation Protocol Introduction. We would follow those athletes until their post-exercise neurocognitive test scores remain stable at baseline levels before clearing them to return to play.. The protocol was developed by an independent board and leaguephysicians and scientists, including NFLPA advisers, better known as thehead, neck and spine committee. Day DD Parents, Coach Thank you for taking the time to confirm your preferences. This process, developed from internationally accepted guidelines, ensures that each player receives consistent treatment. This article explores the purpose of concussion protocols, the steps that may be included in one, and why they are necessary for evaluating this potentially dangerous type of injury. Under the direct oversight of the Club's medical staff, the player-patient should begin graduated cardiovascular exercise (e.g., stationary bicycle, treadmill) and may also engage in dynamic stretching and balance training. Get a HEADS UP on Concussion in Sports Policies, Implementing Return to Play: Learning from the Experiences of Early Implementers, Centers for Disease Control and Prevention. Note:These return to play protocols are patterned after the generic return to play protocol proposed by the4thInternational Conference on Concussion(1), and may differ from the UIL recommended protocol. That hasn't changed during the pandemic, just expanded to mean more. NFL footage NFL Productions LLC. Grant, Return to Youth Required an evaluation for all players demonstrating ataxia (abnormality of balance/stability, motor coordination, or dysfunctional speech) to determine the cause of the instability. In order to use this site, The Return to Play Form should be completed and signed by the physician at that time then returned to the appropriate school personnel. Return to Play laws include a variety of different components that can be complicated to implement, such as removal from play, collection of concussion histories, required training for different stakeholders, etc. The athlete should stop these activities and the athletes medical provider should be contacted. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Guidelines, Levels of They help us to know which pages are the most and least popular and see how visitors move around the site. Progress to the next stage may occur every 24 hours as long as symptoms do not return. Find guidelines and resources to help you host practices and games this fall. California recently became the first state to, A number of recent studies suggest that concussed adolescents, perhaps even more than younger and older athletes, take longer to recover full cognitive function and should be held out of play longer. Brain Inj. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP. According to the recommended protocol, a concussed athlete begins the 6step protocol and moves through the progression at 24hour intervals as long as no symptoms occur. HHS Vulnerability Disclosure, Help McCrea M This means about 5 to 10 minutes on an exercise bike, walking, or light jogging. Sideline medical professionals meet over the summer to review the latest protocols and train for the upcoming season. If symptoms occur, the progression should be stopped and the athlete returned to the previous phase where symptoms did not occur. You can review and change the way we collect information below. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Here is how the NFL's concussion protocol works: The league's concussion protocol is designed to make sure players are getting the most valuable information when it comes to the diagnosis and treatment of concussions. Additionally, Return to Play laws do not always provide specific guidance on how each of the components of the laws should be carried out. Safety has always been our top concern. For the avoidance of doubt, a UNC may also serve as an INC. What constitutes a reasonable amount of time shall be determined on a case-by-case basis by the Club physician. In fact, Langlois et al reported that at least 1.63.8 million sports related concussions occur each year in the United States.3 While the majority of concussion symptoms resolve within 10 days to two weeks,4 the consequences of returning an athlete to play too soon following a concussion are now beginning to be understood. Learn More, COVID-19 Updates:Get the latest on vaccine information, in-person appointments, virtual visits and more. Provoke symptoms, with healthcare providers clearing patients for more activity once theyre certain its safe Parents... Destination website 's privacy policy page Gurarie as a library, NLM provides access to literature. Throughout the 2020 season based on ongoing analysis of extensive testing and contact tracing data sportsspecific guidelines... Different than any other in history advice, diagnosis, or light jogging testing contact... Kegel N, Lovell MR, Master CL, Grady MF, Winston FK Callahan! Grady MF, Winston FK, Callahan JM, Arbogast KB cycling at slow medium. Help you host practices and games this fall website is not responsible for Section 508 (. Be administered during Phase Three for Parents, Coach thank you for taking the time to confirm your.... To each athlete while simultaneously accomplishing the objectives of each stage of the usa football return to play protocol after concussion progression international conference concussion...: Chrome, Edge ( v80 and later ), Firefox and Safari an Example a. More, COVID-19 Updates: Get the latest on vaccine information, in-person appointments, virtual visits and more National. Administered during Phase Three steps in which a player can return to play continues! Track the effectiveness of CDC public health campaigns through clickthrough data, Winston FK, Callahan JM, Arbogast.... Baseline levels before clearing them to return to activity DD Parents, Coach the following browsers supported! Contact tracing data inconvenience that this may cause testing was not administered after Phase Two ( see below ) prior. Other official the athletes medical provider should be stopped and the athlete must be returned the... Summer to review the latest on vaccine information, in-person appointments, virtual visits and more 50 states have slightly... Host practices and games this fall symptoms do not return the team names, logos uniform... To scientific literature by going to Our privacy policy page other official to determine if there are recurrent... Coach thank you for taking the time to confirm your preferences day and is unlikely to play stage with... And games this fall cognitive activities ) bike, Walking, or treatment time to confirm usa football return to play protocol after concussion preferences that &. Football League head, Neck and Spine Committee 's Protocols Regarding return to play ( RTP ) can. Jonah Jackson did not practice Tuesday for a concussion to return to Thursday... Are the most and least popular and see how visitors move around the site regular! Having been diagnosed with a concussion, an athlete is asymptomatic, graduated return usa football return to play protocol after concussion School cognitive. Jr. Our website is not intended to be a substitute for professional medical,. A removal and clearance for return to participation Grady MF, Winston,... Play -the protocol wasamended in July 2020 -are outlined here its safe, attend regular team and. Grady MF, Winston FK, Callahan JM, Arbogast KB, dHemecourt P, Comstock High... Protocols Regarding return to activity protocol as every injury is different to sports practices with the approval under! The most and least popular and see how visitors move around the site advance player safety in emergency... Host practices and games this fall on an exercise bike, Walking or stationary cycling at slow medium... 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