What is the recommended protocol for return to play following a concussion?

Return to Play Following Concussion

Athletes with concussion must never return to play on the same day of injury and should follow a structured 6-stage protocol requiring a minimum of 5 days, with each stage lasting at least 24 hours, progressing only when completely asymptomatic at rest and with exertion. 1, 2

Absolute Contraindications to Same-Day Return

• No athlete should return to play the same day of concussion under any circumstances 1, 2
• The principle "When in doubt, sit them out!" is paramount in concussion management 1, 2
• Any athlete showing ANY symptoms or signs of concussion must be immediately removed from play and not allowed to return to the current game or practice 1, 2

Prerequisites Before Starting Return-to-Play Protocol

The athlete must be completely asymptomatic both at rest AND with exertion before beginning the graduated protocol 1, 2

Key Requirements:

• No symptoms during rest 1
• No symptoms with physical exertion 1
• Normal neurological examination 1, 2
• Normal cognitive function (particularly important in pediatric/adolescent athletes who require 7-10 days or longer for full cognitive recovery) 1

The 6-Stage Graduated Return-to-Play Protocol

Each stage must last a minimum of 24 hours, requiring at least 5 days total before full return to competition 1, 2

Stage 1: No Activity

• Complete physical and cognitive rest 1
• Continue until asymptomatic at rest 1

Stage 2: Light Aerobic Activity

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

Stage 3: Sport-Specific Exercise

• Sport-related drills (e.g., skating drills in hockey, running drills in soccer) 1
• No head impact activities 1
• Goal: add movement and coordination 1

Stage 4: Non-Contact Training Drills

• More complex training drills 1
• May start light resistance training 1
• Goal: exercise, coordination, and cognitive load 1

Stage 5: Full-Contact Practice

• Requires medical clearance from a licensed healthcare professional before this stage 1, 2
• Participate in normal training activities 1
• Goal: restore confidence and assess functional skills 1

Stage 6: Return to Play

• Normal game play 1

Critical Management Rules

If Symptoms Recur During Protocol:

• Stop immediately at the current stage 1, 2
• Wait until asymptomatic for at least 24 hours 1, 2
• Resume at the previous asymptomatic level (drop back one stage) 1, 2
• Contact healthcare provider if symptoms recur 1

Special Populations Requiring Longer Recovery:

Pediatric and adolescent athletes require more conservative management 1

• Cognitive recovery takes 7-10 days or longer in younger athletes (compared to college-aged or professional athletes) 1
• More conservative approach mandatory even when asymptomatic 1

Athletes with multiple concussions or prolonged symptoms 1, 2

• Require longer concussion-rehabilitation programs 1
• Should be managed by a physician experienced in concussion management 1

Common Pitfalls to Avoid

• Never skip stages in the protocol, even if the athlete appears to be recovering quickly 2
• Never allow premature return to play, which increases risk of prolonged recovery or second impact syndrome 2
• Do not assume symptom resolution means full cognitive recovery, especially in younger athletes 1
• Avoid prolonged complete rest beyond 24-48 hours, as this can be detrimental to recovery 3

Monitoring and Supervision

• Progress may be monitored by parents or athletic trainers with proper instructions 1
• The athlete should not be left alone during acute phase and requires regular monitoring for deterioration 1, 2
• Medical evaluation is mandatory after the injury 1, 2