What is the return to activity protocol for an athlete with a suspected concussion and persistent headache?

Return to Activity Protocol for Athletes with Concussion

Athletes with concussion should never return to play while symptomatic at rest or with exertion, and must follow a stepwise progression with minimum 24 hours per step before returning to full activity. 1, 2

Initial Management of Persistent Headache

When an athlete presents with a persistent headache following a suspected concussion, this indicates ongoing symptoms that require proper management before any return to activity can be considered. The presence of headache is the most frequently reported symptom of concussion 3 and requires careful attention.

• Immediately remove the athlete from all physical activity
• Ensure both physical AND cognitive rest until symptoms begin to improve 2
• Monitor for worsening symptoms which may indicate more serious injury 2
• Avoid same-day return to play even if symptoms appear to resolve 1, 2

Stepwise Return to Activity Protocol

The American Academy of Pediatrics and British Journal of Sports Medicine recommend a structured, gradual return to play protocol 1, 2. Each step requires a minimum of 24 hours, and if symptoms recur at any step, the athlete must return to the previous asymptomatic level for at least 24 hours before attempting to progress again.

1. Step 1: No activity

   • Complete physical and cognitive rest
   • Goal: Recovery and symptom resolution

2. Step 2: Light aerobic exercise

   • Walking, swimming, or stationary cycling at low intensity
   • No resistance training
   • Goal: Increase heart rate

3. Step 3: Sport-specific exercise

   • Running drills or skating drills (sport-specific)
   • No head impact activities
   • Goal: Add movement

4. Step 4: Non-contact training drills

   • More complex training drills (e.g., passing drills)
   • May start progressive resistance training
   • Goal: Exercise, coordination, and cognitive load

5. Step 5: Full-contact practice

   • Following medical clearance
   • Normal training activities
   • Goal: Restore confidence and assess functional skills

6. Step 6: Return to play/competition

   • Normal game play
   • Only after medical clearance from a healthcare professional

Important Considerations

• Medical clearance is mandatory: Any pediatric or adolescent athlete with a concussion must be evaluated by a healthcare professional, ideally a physician with experience in concussion management, before returning to play 1

• Symptom monitoring: The athlete should be regularly monitored for symptom recurrence during the return-to-play progression 2

• Academic accommodations: Students may require cognitive rest and academic accommodations such as reduced workload and extended time for tests while recovering 3

• Recovery timeline: While most concussion symptoms typically resolve in 7-10 days, some athletes may take weeks to months to recover completely 1

• Age considerations: The recovery course is longer for younger athletes than for college and professional athletes, warranting a more conservative approach 1

Common Pitfalls to Avoid

1. Premature return to activity: Returning too soon increases risk of prolonged symptoms and second-impact syndrome, which can be catastrophic particularly in athletes under 20 years old 1

2. Ignoring persistent symptoms: Headaches that persist beyond expected recovery time may indicate postconcussion syndrome and require specialized evaluation 1

3. Complete inactivity ("cocooning"): Recent evidence suggests that complete rest or "cocooning" may actually prolong recovery; a gradual return to cognitive and physical activity is recommended 4

4. Relying solely on athlete self-reporting: Athletes may underreport symptoms to expedite return to play; objective assessment tools should be used in conjunction with clinical judgment 5

5. Neglecting academic needs: Failure to provide appropriate academic accommodations can exacerbate symptoms and delay recovery 3

The presence of persistent headache indicates that the athlete is not ready for return to play. The athlete should be monitored regularly, and if symptoms persist beyond the expected recovery period, referral to a specialist with expertise in sport-related concussion is recommended 1.