What is the stepwise protocol for managing a concussion from the beginning?

Stepwise Protocol for Managing a Concussion

The stepwise protocol for managing a concussion begins with immediate removal from play, followed by a period of physical and cognitive rest until asymptomatic, then progressing through a 5-step return-to-play protocol with each step taking at least 24 hours, requiring medical clearance before full return to competition. 1

Initial Management

1. Immediate Removal from Play

   • Remove athlete from play immediately when concussion is suspected
   • Follow the principle: "When in doubt, sit them out!" 1
   • Under NO circumstances should an athlete return to play on the same day of injury 2, 1

2. Evaluation by Healthcare Professional

   • Assessment should include:
     • Symptom checklist
     • Cognitive evaluation (orientation, memory, concentration)
     • Balance testing
     • Neurological examination 3
   • Routine imaging is NOT recommended for uncomplicated concussion 1, 3

3. Initial Rest Period

   • Complete physical and cognitive rest until asymptomatic 2, 1
   • This may include limiting screen time, reading, and other mentally stimulating activities

Return-to-Play Protocol

Once the athlete is completely asymptomatic at rest for 24 hours, they may begin the stepwise return-to-play protocol:

1. Step 1: No Activity

   • Complete physical and cognitive rest until asymptomatic for 24 hours 2, 1

2. Step 2: Light Aerobic Exercise

   • Walking, swimming, or stationary cycling at 70% maximum heart rate
   • No resistance training
   • Purpose: Increase heart rate 2, 1

3. Step 3: Sport-Specific Exercise

   • Running drills, sport-specific movements
   • No head impact activities
   • Purpose: Add movement 2, 1

4. Step 4: Non-Contact Training Drills

   • More complex drills
   • May begin light resistance training
   • Purpose: Exercise, coordination, and cognitive load 2, 1

5. Step 5: Full-Contact Practice

   • Only after medical clearance
   • Normal training activities
   • Purpose: Restore confidence and assess functional skills 2, 1

6. Step 6: Return to Competition

   • Normal game play 2, 1

Important Protocol Rules

• Each step must take a minimum of 24 hours 2, 1
• The entire protocol requires a minimum of 5 days to complete 2, 1
• If symptoms return during any step, the athlete must:
  • Stop activity immediately
  • Rest until asymptomatic for at least 24 hours
  • Return to the previous asymptomatic level 2, 1
• Medical clearance is required before progressing to full-contact practice (Step 5) 1

Special Considerations

• Younger Athletes: Require more conservative management with potentially longer recovery times 1, 3
• Previous Concussion History: Increases risk for subsequent concussions and may require more conservative management 1
• Multiple Concussions: May need consideration for temporary or permanent disqualification from contact sports 1
• Academic Accommodations: Students may require cognitive rest and academic accommodations during recovery 3

Common Pitfalls to Avoid

• Same-day return to play - Never allow an athlete to return to play on the same day of injury, even if symptoms resolve quickly 2, 1
• Skipping steps - Don't allow athletes to skip steps or progress faster than 24 hours per step 1
• Ignoring symptom recurrence - Any return of symptoms indicates inadequate recovery and requires stopping the progression 2, 1
• Inadequate medical clearance - Full-contact practice should only occur after proper medical clearance 1
• Premature return - Returning too early increases risk of prolonged symptoms and potential second-impact syndrome 1

This stepwise protocol ensures a safe, gradual return to play following concussion, minimizing the risk of reinjury and long-term complications.