What is the recommended management and return to play protocol for an athlete with a sports concussion?

Management and Return to Play Protocol for Sports Concussion

Any athlete with a suspected concussion must be immediately removed from play and cannot return to competition the same day, even if symptoms resolve—"When in doubt, sit them out!" 1

Immediate Management

Recognition and Removal

• Remove the athlete from play immediately upon suspicion of concussion, regardless of symptom severity 1, 2
• Loss of consciousness occurs uncommonly and is not required for diagnosis; if LOC exceeds 30 seconds, consider more significant intracranial injury 1
• Delayed removal from activity after concussion increases recovery time by approximately 5 days and doubles the risk of prolonged recovery (≥8 days) 3

Initial Evaluation

• Evaluate using a standardized symptom checklist, cognitive assessment (orientation, memory, concentration), and balance testing 1, 2
• Neuroimaging (CT/MRI) is typically normal in concussion but should be obtained if severe mechanism, significant LOC, focal neurologic deficits, or deteriorating symptoms are present 1, 4
• Monitor for neurological deterioration in the hours following injury 1, 2

Treatment Phase

Complete Rest Period

• Prescribe complete physical AND cognitive rest until all symptoms resolve both at rest and with exertion 1
• Cognitive rest includes reducing schoolwork, limiting screen time, and avoiding mentally demanding activities 1
• Coordinate with teachers and school administrators to modify academic workloads during recovery 1, 2
• Most concussions resolve within 7-10 days, though pediatric and adolescent athletes typically require longer recovery than college or professional athletes 1

Medical Clearance

• Require evaluation and clearance by a healthcare professional experienced in concussion management before initiating return-to-play protocol 1, 2
• Neuropsychological testing may provide objective data but should not be used in isolation for diagnosis or return-to-play decisions 1, 2

Stepwise Return-to-Play Protocol

Once completely asymptomatic at rest, begin the following 6-stage protocol, with each stage lasting a minimum of 24 hours (minimum 5 days total): 1, 5

Stage 1: No Activity

• Complete physical and cognitive rest 1, 5

Stage 2: Light Aerobic Activity

• Walking, swimming, or stationary cycling at ≤70% maximum heart rate 1, 5
• No resistance exercises 1, 5

Stage 3: Sport-Specific Exercise

• Sport-specific drills (e.g., skating in hockey, running in soccer) with no head impact 1, 5

Stage 4: Non-Contact Training Drills

• More complex training drills; may begin light resistance training 1, 5

Stage 5: Full-Contact Practice

• Normal training activities after medical clearance 1, 5

Stage 6: Return to Play

• Normal game participation 1, 5

Critical Protocol Rules

• If ANY symptoms return at any stage, stop immediately 1, 5
• Once asymptomatic for 24 hours, drop back to the previous asymptomatic level and attempt progression again 1, 5
• Contact healthcare provider if symptoms recur during the protocol 1

Special Considerations

Pediatric and Adolescent Athletes

• Use a more conservative approach as younger athletes demonstrate longer cognitive recovery (often 7-10 days or longer) compared to college/professional athletes 1, 5
• Never return pediatric or adolescent athletes to play on the same day of concussion, even if asymptomatic 1

Multiple Concussions or Prolonged Symptoms

• Athletes with multiple concussions or symptoms lasting beyond typical timeframes require longer, individualized rehabilitation programs supervised by experienced physicians 1, 2
• Consider retirement from contact/collision sports for athletes with history of multiple concussions or persistent long-term symptoms 1, 2

Medications

• The safety and efficacy of medications for sport-related concussion management has not been established 1
• For prolonged symptoms, medications may be considered for specific issues like headaches, mood disturbances, or sleep problems 6

Common Pitfalls to Avoid

• Never allow same-day return to play, even if the athlete appears asymptomatic—this is the most critical error that increases risk of prolonged recovery and potential catastrophic injury 1, 3
• Do not rely solely on neuropsychological testing for return-to-play decisions; it is only one component of comprehensive management 1, 2
• Do not advance through the return-to-play protocol faster than 24 hours per stage, even if the athlete feels ready 1, 5
• Approximately 50% of concussions go unreported; educate athletes, parents, and coaches about the importance of immediate reporting 2