If symptoms return during a return-to-play (RTP) protocol step, do you repeat the current step or return to the previous step after 24 hours asymptomatic?

Return-to-Play Protocol After Symptom Recurrence

If symptoms return during a return-to-play (RTP) protocol step, the athlete should return to the previous asymptomatic level after being symptom-free for 24 hours. 1, 2

Understanding the Return-to-Play Protocol

The return-to-play protocol after concussion follows a stepwise progression:

1. No activity - Complete physical and cognitive rest
2. Light aerobic exercise - Walking, swimming, stationary cycling at 70% maximum heart rate
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
6. Return to play - Normal game play

Key Protocol Rules:

• Each step requires a minimum of 24 hours 1
• The athlete must be completely asymptomatic before progressing to the next step 1
• A minimum of 5 days is required to complete the full protocol 1, 2

Managing Symptom Recurrence

When symptoms recur during any step of the protocol:

1. Stop activity immediately 1, 2
2. Rest completely until asymptomatic for at least 24 hours 1, 2
3. Return to the previous asymptomatic level (not repeat the current level) 1, 2
4. Attempt to progress again after being symptom-free for 24 hours 1

Example Scenario:

If an athlete progresses to Step 3 (Sport-specific exercise) and develops symptoms:

• Stop all activity immediately
• Rest until completely asymptomatic for 24 hours
• Return to Step 2 (Light aerobic exercise)
• Remain at Step 2 for at least 24 hours before attempting to progress to Step 3 again

Common Pitfalls to Avoid

• Rushing the process: Each step must take a minimum of 24 hours, with a total minimum of 5 days to complete the protocol 1, 2
• Same-day return: Never allow an athlete to return to play on the same day symptoms occur 1, 2
• Skipping steps: Athletes must progress through each step sequentially 1
• Ignoring mild symptoms: Any symptom recurrence indicates inadequate recovery and requires stopping the current step 1, 2
• Failing to contact healthcare provider: Athletes should contact their healthcare provider if symptoms recur 1

Special Considerations

• Athletes with multiple concussions or prolonged symptoms may require a longer rehabilitation program 1, 2
• Younger athletes typically need more conservative management with longer recovery periods 1, 2
• A physician experienced in concussion management should ideally create the rehabilitation program for complex cases 1

The principle of "When in doubt, sit them out!" remains paramount in concussion management to prevent potential cumulative brain damage and second-impact syndrome 1, 2.