What are the guidelines for a return to play exam following a possible concussion?

Return to Play Exam Following a Possible Concussion

An athlete with a possible concussion must never return to play the same day and should only be cleared after being completely asymptomatic at rest and with exertion, followed by successful completion of a medically supervised 6-stage return-to-play protocol requiring a minimum of 5 days. 1, 2

Immediate Management

Remove the athlete from play immediately if ANY concussion symptoms are present, including headache, dizziness, confusion, balance problems, or altered mental status. 1

• The athlete must not be left alone and requires regular monitoring for neurological deterioration 1
• Medical evaluation by a licensed healthcare professional experienced in concussion management is mandatory before any consideration of return to play 1, 2
• "When in doubt, sit them out" is the guiding principle 1

Prerequisites for Starting Return-to-Play Protocol

The athlete must meet ALL of the following criteria before beginning the stepwise protocol:

• Complete resolution of symptoms at rest (no headache, dizziness, cognitive difficulties, or other concussion symptoms) 1, 2
• Complete resolution of symptoms with exertion (symptoms do not return with physical or cognitive activity) 1
• Normal neurological examination 1
• Normal cognitive evaluation (return to baseline academic performance and cognitive testing if available) 1

The 6-Stage Return-to-Play Protocol

Each stage must last a minimum of 24 hours, making the fastest possible return 5 days from starting the protocol: 1, 2

Stage 1: Complete Rest

• No physical or cognitive activity beyond activities of daily living 1, 2
• Continue until completely asymptomatic at rest 1, 2

Stage 2: Light Aerobic Activity

• Walking, swimming, or stationary cycling at ≤70% maximum heart rate 1, 2
• No resistance training 1, 2
• Goal: increase heart rate without symptom recurrence 1

Stage 3: Sport-Specific Exercise

• Sport-related drills (e.g., running drills, skating, passing) without any head impact 1, 2
• Still no resistance training 1

Stage 4: Non-Contact Training Drills

• More complex training drills and coordination exercises 1, 2
• May begin light resistance training 1, 2
• Still no body contact or head impact 1

Stage 5: Full-Contact Practice

• Requires formal medical clearance from a licensed healthcare provider before this stage 1, 2
• Participate in normal training activities with full contact 1, 2

Stage 6: Return to Game Play

• Normal unrestricted competition 1, 2

Critical Management Rules

If ANY symptoms return at any stage:

• Stop activity immediately 1, 2
• Rest until asymptomatic for at least 24 hours 1, 2
• Drop back to the previous asymptomatic stage and attempt progression again 1, 2
• Contact the healthcare provider if symptoms recur 1, 2

Special Considerations for Pediatric and Adolescent Athletes

Younger athletes require more conservative management than adults: 1, 2

• Cognitive recovery typically takes 7-10 days or longer in pediatric/adolescent athletes compared to college or professional athletes 1, 2
• Even when asymptomatic, brain function may not be fully recovered 1
• A more conservative, longer timeline should be applied to younger athletes 1

High-Risk Situations Requiring Extended Recovery

Athletes with the following should have longer, individualized protocols created by a physician experienced in concussion management: 1, 2

• History of multiple concussions 1, 2
• Prolonged symptom duration (>10 days) 1, 2
• History of prolonged recovery from previous concussions 1

Consider retirement from contact sports for athletes with multiple concussions or persistent symptoms 2

Common Pitfalls to Avoid

• Never clear an athlete to return the same day as injury, regardless of how quickly symptoms resolve 1
• Do not rely solely on the athlete's self-report of symptoms—they may minimize symptoms to return to play faster 1
• Do not skip stages or shorten the 24-hour minimum duration per stage 1, 2
• Do not allow progression to full-contact practice (Stage 5) without documented medical clearance 1, 2
• Remember that being asymptomatic does not equal full cognitive recovery, especially in younger athletes 1