What are the current guidelines for return to play after a concussion in school athletes?

Current Concussion Return-to-Play Guidelines for School Athletes

School athletes who sustain a concussion must follow a stepwise return-to-play protocol requiring at least 5 days after becoming asymptomatic, with each step taking a minimum of 24 hours and mandatory medical clearance before returning to full contact sports. 1

The 6-Step Return-to-Play Protocol

The American Academy of Pediatrics recommends a structured, gradual return-to-play (RTP) protocol consisting of the following steps:

1. No activity: Complete physical and cognitive rest until asymptomatic
2. Light aerobic exercise: Only when completely symptom-free for 24 hours
3. Sport-specific exercise: Running drills, no head impact activities
4. Non-contact training drills: More complex training, progressive resistance
5. Full-contact practice: Only after medical clearance
6. Return to competition: Only after completing all previous steps without symptoms 1

Key Protocol Requirements:

• Each step requires a minimum of 24 hours
• The athlete must be completely asymptomatic at each stage before progressing
• If any symptoms return during a step, the protocol must restart from the beginning
• Total minimum time: 5 days after becoming asymptomatic 1

Medical Evaluation and Clearance

• Mandatory medical clearance from a licensed healthcare provider trained in concussion management is required before returning to contact sports 1
• Healthcare professionals should conduct cognitive assessments including:
  • Orientation testing
  • Memory evaluation
  • Concentration testing 1
• Athletes should not take medications that mask concussion symptoms during the RTP protocol 1

Special Considerations for School Athletes

Age-Specific Approach

• Younger athletes typically require longer recovery periods compared to college-aged or professional athletes 1
• A more conservative approach is recommended for pediatric athletes, with slower progression through the protocol stages 2

Athletes with Multiple Concussions

• Previous concussion history increases risk for subsequent concussions
• May require more conservative management
• Consider temporary or permanent disqualification from contact sports if symptoms persist beyond expected recovery 1

School Integration

• Athletes are typically returning to school with accommodations more quickly than returning to full athletic activity 3
• Full contact sport (stage 6) should be delayed until full and successful reintegration back to school has been achieved 3

Common Pitfalls to Avoid

1. Rushing the protocol: Each step requires a minimum of 24 hours, even if the athlete appears asymptomatic
2. Inadequate symptom monitoring: Athletes should be regularly evaluated by healthcare professionals during the RTP progression
3. Ignoring recurrent symptoms: Any symptom exacerbation should trigger a return to the previous step
4. Failing to obtain proper medical clearance: Required before advancing to full-contact practice
5. Overlooking cognitive recovery: School performance should be considered alongside physical recovery 1, 3

Sport-Specific Considerations

Some sports may benefit from modified RTP protocols that maintain the integrity of the six-step model while adding sport-specific drills and activities. These sports include football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey 2.

The final RTP determination must always occur with documented medical clearance from a licensed healthcare provider trained in concussion evaluation and management 2.