What is the return of play (ROS) protocol for a concussion?

Return to Play Protocol for Concussion

Athletes with concussion must follow a structured 6-step gradual return to play protocol, with each step taking a minimum of 24 hours, requiring at least 5 days total before full competition, and no athlete should return to play on the day of injury or while symptomatic. 1

Immediate Management

Never allow same-day return to play under any circumstances. 1, 2 The phrase "When in doubt, sit them out!" is paramount in concussion management. 1, 2

• Any athlete showing symptoms or signs of concussion must be immediately removed from play and not allowed to return until evaluated by a licensed healthcare professional trained in concussion management. 1, 2
• Athletes should not be left alone, and regular monitoring for deterioration is essential. 1
• Complete physical and cognitive rest is required for the first 24-48 hours after injury. 2

Prerequisites Before Starting Return to Play Protocol

Before beginning the stepwise protocol, the athlete must meet ALL of the following criteria:

• Completely asymptomatic at rest (no symptoms without exertion). 1
• Normal neurological examination. 1
• Not taking any medications for concussion symptoms. 1, 2
• Medical clearance from a licensed healthcare provider trained in concussion evaluation and management. 1, 3

The 6-Step Gradual Return to Play Protocol

Each stage must last at least 24 hours, meaning a minimum of 5 days is required to progress through the entire protocol before returning to competition. 1

Stage 1: No Activity

• Complete physical and cognitive rest until asymptomatic. 1
• Limit activities requiring concentration: reading, video games, computers, television, loud music, and bright lights. 2

Stage 2: Light Aerobic Exercise

• Walking, swimming, or stationary cycling at ≤70% maximum heart rate. 1
• No resistance training at this stage. 1
• Goal: increase heart rate without provoking symptoms. 1

Stage 3: Sport-Specific Exercise

• Sport-specific drills (e.g., skating in hockey, running in soccer). 1
• No head impact activities. 1
• May begin light resistance training. 1

Stage 4: Non-Contact Training Drills

• More complex training drills specific to the athlete's sport and position. 1
• Progressive resistance training may continue. 1
• Still no contact or collision activities. 1

Stage 5: Full-Contact Practice

• Only after medical clearance can the athlete participate in normal full-contact training activities. 1
• This allows final assessment of functional skills before game play. 1

Stage 6: Return to Normal Game Play

• Unrestricted participation in competition. 1

Management of Symptom Recurrence

If ANY symptoms return at any stage, the athlete must immediately stop activity. 1

• The athlete should rest until asymptomatic for at least 24 hours. 1
• Once asymptomatic again, drop back to the previous asymptomatic level and attempt to progress again. 1
• Athletes should contact their healthcare provider if symptoms recur during the protocol. 1

Special Considerations for Pediatric and Adolescent Athletes

Younger athletes require more conservative management because they demonstrate longer cognitive recovery periods (often 7-10 days or longer) compared to college-aged or professional athletes. 1

• Each step may need to take longer than 24 hours in pediatric populations. 1
• Athletes with multiple concussions or prolonged symptoms require an extended, individualized rehabilitation program created by a physician experienced in concussion management. 1
• Consider temporary school accommodations including shortened days, reduced workloads, extended time for assignments, and postponement of standardized testing. 2

Critical Pitfalls to Avoid

• Premature return to play increases risk of decreased cognitive ability, slower reaction time, prolonged symptoms, and risk of more severe reinjury. 1, 2
• Ignoring subtle symptoms during exertion—athletes must be completely asymptomatic both at rest AND with exertion before advancing. 1
• Allowing medication to mask symptoms—do not return to play while taking medications for concussion symptoms. 1, 2
• Inadequate cognitive rest—cognitive demands can delay recovery as much as physical activity. 2

Warning Signs Requiring Immediate Medical Attention

Seek emergency care immediately if the athlete develops:

• Loss of consciousness or altered mental status. 2
• Severe or worsening headache. 2
• Repeated vomiting. 2
• Seizures. 2
• Visual changes or pupil abnormalities. 2
• Swelling or deformities of the scalp. 2

Management of Persistent Symptoms (>10 Days)

Athletes with symptoms persisting beyond 10 days require multidisciplinary management. 1, 2

• Consider referral to specialists experienced in concussion management. 2
• May benefit from graded physical exercise programs, vestibular rehabilitation, or manual therapy of the neck and spine under professional guidance. 2
• Neuropsychological testing can assist in return to play decisions but should not substitute for clinical evaluation. 1