Pillar Five: Cautious Return to Play

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For the last sixteen years, the most commonly utilized return to play (RTP) protocol after a child or teen suffers a sport concussion is the six step, exercise-limited process recommended in international concussion consensus statements, most recently issued in 2017. (1) The recommended six-step process is as follows:

1. Symptom-limited activity.  After a brief period of initial rest (24 to 48 hours), daily activities can be begun which do not provoke symptoms.  The goal is to gradually reintroduce work/school activities.

2. Light aerobic exercise such as 5 to 10 minutes on an exercise bike, walking, swimming or light jogging, at 70% or less of maximum permitted heart rate, but no resistance training. Monitor for a return of any symptoms. If no symptoms recur, progress in 24 hours to Step 3. If symptoms recur, wait 24 hours, and, if symptoms clear, try again.

3. Sport-specific exercise. Continue with moderate jogging, brief running, moderate-intensity stationary biking. No head impact activities. If no symptoms recur, progress in 24 hours to Step 4. If symptoms recur, wait 24 hours, and, if symptoms clear, try again.

4. Non-contact training drills: more complex training drills, e.g. passing drills, running plays without pads or contact. May start progressive resistance/weight training. If no symptoms recur, progress in 24 hours to Step 5. If symptoms recur, wait 24 hours, and, if symptoms clear, try again.

5. Full-contact practice: Following medical clearance (now required in all U.S. states), an athlete may participate in normal training activities. Such participation helps to restore the athlete’s confidence (remember: psychological readiness for a return to play is just as important as physical readiness), and allows the coaching staff to assess the extent to which the athlete is ready for game action. Again, if symptoms recur, wait 24 hours, and, if symptoms clear, try again.

6. Return to play with medical authorization

Generally, each step takes at least 24 hours (concussion symptoms, of course, may take much longer in some cases to clear), so that an athlete whose symptoms clear within the first 24 hours after injury will take approximately 1 week to complete the full rehabilitation protocol once they are asymptomatic at rest and with exercise.

It is important to note that there are, as of yet, no peer reviewed studies establishing that employing the six-step protocol significantly reduces the risk that an athlete will suffer another concussion or reduces the risk of long-term injury.

Experts also caution that, while an estimated 80 to 90% of concussions heal spontaneously in the first 7 to 10 days, a more conservative RTP approach is recommended for children and adolescents, as they may require a longer rest period and/or extended period of non-contact exercise than adults because their developing brains cause them to experience a different physiological response to concussion than adults and to take longer to recover. (the expected duration of symptoms in children with sports-related concussion is up to four weeks) (1)

In the absence of daily testing by a health care professional with concussion expertise (certified athletic trainer, school/team physician) to clear a student-athlete to begin the graduated return-to-play protocol, a student-athlete should observe a 7 day rest/recovery period before even commencing the protocol. This means that, for such athletes, return to sports will take at least two weeks. Some leading concussion experts, including one, Dr. Rosemarie Scolaro Moser, featured in The Smartest Team, believe that three weeks off from sports is appropriate after concussion. (2)

Younger students (K-8), should observe the 7 day rest/recovery period after they are symptom-free at rest prior to initiating the graduated-return-to play protocol.

As young athletes tend to consider only a small subset of their potential symptoms when reporting their recovery or saying they are “back to normal” after concussion, caution is urged in considering athletes’ self-reported symptoms (3) in their return-to-play decisions, and the same caution is warranted in relying solely on neurocognitive test scores having returned to normal before the graduated exercise protocol is begun.

Indeed, a recent study (4) of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated exercise protocol, found that more than a quarter exhibited declines in verbal and visual memory on the tests after moderate exercise, prompting a recommendation that student-athletes not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on neurocognitive concussion testing performed after the exercise protocol is begun. While this was just one study, additional post-exercise neurocognitive testing may eventually become an important part of the RTP protocol.


  1. McCrory P, Meeuwisse W, Dvorak J., et. al. Consensus Statement on Concussion in Sport: the 5th International Conference on Concussion in Sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.
  2. Moser R. Ahead of the Game: The Parents’ Guide to Youth Sports Concussion (Dartmouth College Press 2012), p. 102.
  3. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology: Child. 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012)
  4. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP.  Post-exertion neurocognitive test failure among student-athletes following concussion.  Brain Injury 2013;27(1):103-113.
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