What are the guidelines for an athlete to return to play after a concussion?

Guidelines for Return to Play After Concussion

Athletes with concussion should follow a stepwise return-to-play protocol that requires them to be completely asymptomatic at rest and with exertion before beginning a minimum 5-day progression through rehabilitation stages, with each stage lasting at least 24 hours. 1

Initial Management

• Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion 2
• The principle "When in doubt, sit them out!" is paramount in concussion management 2
• Any athlete suspected of having a concussion must be immediately removed from play and evaluated by a healthcare professional 1, 3
• No athlete should return to play while still symptomatic at rest or with exertion 2

Recovery Considerations

• Younger athletes typically demonstrate longer recovery times compared to college-aged or professional athletes, often requiring 7-10 days or longer 2
• This longer cognitive recovery period necessitates a more conservative approach to return-to-play decisions for pediatric and adolescent athletes 2
• Athletes with multiple concussions or prolonged symptoms may require a longer rehabilitation program 2

Stepwise Return-to-Play Protocol

The following 6-stage protocol must be followed, with each stage lasting a minimum of 24 hours 2:

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

Important Protocol Guidelines

• The entire protocol requires a minimum of 5 days to complete, assuming no return of symptoms 2
• If symptoms recur during any stage, the athlete must stop immediately 2
• Once asymptomatic for at least 24 hours after symptom recurrence, the athlete should return to the previous asymptomatic stage and attempt to progress again 2
• Athletes should contact their healthcare provider if symptoms recur 2
• Medical clearance from a licensed healthcare professional is required before returning to full-contact practice (stage 5) 2, 1

Special Considerations

• Athletes with multiple concussions or prolonged symptoms require a more cautious approach and potentially longer rehabilitation program 2, 1
• Research indicates that high school athletes report more concussion symptoms than youth athletes, which may influence recovery time 4
• Youth athletes have been shown to have higher odds of both prolonged recovery (≥30 days) and premature return to play (<24 hours) compared to older athletes, highlighting the need for careful monitoring 4

Common Pitfalls to Avoid

• Allowing same-day return to play, which is absolutely contraindicated for pediatric and adolescent athletes 2
• Progressing through protocol stages too quickly (each stage must last at least 24 hours) 2
• Failing to recognize that symptom resolution at rest does not indicate complete recovery 2, 1
• Overlooking the need for medical clearance before returning to contact activities 2, 1
• Inadequate monitoring for symptom recurrence during the return-to-play progression 2