What are the guidelines for returning to play after a sports-related head injury?

Sports-Related Head Injury Return to Play Guidelines

Athletes with sports-related head injuries should never return to play while symptomatic and must follow a structured, stepwise return-to-play protocol that requires a minimum of 5 days to complete, with each stage lasting at least 24 hours. 1

Immediate Management

• "When in doubt, sit them out!" - Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion 1
• Any athlete suspected of having a concussion must be immediately removed from play
• The athlete must be medically evaluated after the injury before considering any return to play

Stepwise Return to Play Protocol

The following 6-step protocol must be followed after a concussion:

1. No activity: Complete physical and cognitive rest until asymptomatic
2. Light aerobic exercise: Walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises
3. Sport-specific exercise: Sport-related drills without head impact
4. Non-contact training drills: More complex drills, may start light resistance training
5. Full-contact practice: Only after medical clearance, participate in normal training
6. Return to play: Normal game play

Key Protocol Requirements:

• Each step requires a minimum of 24 hours
• A minimum of 5 days is required to progress through all steps 1
• Athlete must remain asymptomatic to progress to the next level
• If symptoms recur, the athlete must stop immediately
• Once asymptomatic again for 24 hours, the athlete returns to the previous asymptomatic level 1
• Medical clearance is required before progressing to full-contact practice

Special Considerations

Age-Related Differences

• Younger athletes (pediatric and adolescent) demonstrate longer recovery of full cognitive function compared to college-aged or professional athletes - often 7-10 days or longer 1
• A more conservative approach should be taken with younger athletes

Multiple Concussions

• Athletes with multiple concussions or prolonged symptoms may require a longer concussion-rehabilitation program 1
• Such programs should ideally be created by a physician experienced in concussion management

Protective Equipment

• While helmets can reduce impact forces to the head in laboratory studies, they have not consistently shown reduction in concussion incidence 1
• Mouth guards are recommended to reduce dental trauma but have not been conclusively proven to reduce concussion risk 1

Common Pitfalls to Avoid

1. Premature return: Allowing an athlete to return to play while still symptomatic increases risk of prolonged recovery and potential second impact syndrome
2. Skipping steps: Each step in the protocol serves a specific purpose in testing the brain's recovery
3. Inadequate rest: Complete cognitive and physical rest is essential in the initial recovery phase
4. Ignoring symptom recurrence: Any return of symptoms indicates inadequate recovery and requires stepping back in the protocol
5. Failing to obtain medical clearance: A licensed healthcare provider trained in concussion management must provide clearance before return to full-contact activities

Remember that the brain cannot be conditioned to withstand injury. The primary focus should always be on the athlete's long-term health and well-being rather than expediting return to play.