Step-by-Step Return to Play After Concussion Recommended

Return to play (RTP) after a child or teen suffers a sport concussion is a step by step process:

  1. Physical and mental rest while experiencing symptoms

  2. Exercise program of gradually increased intensity (but only after symptoms clear)

  3. Medical clearance

  4. Return to play

Physical and mental rest

While a child or teen is experiencing post-concussion symptoms, it is very important that he not only limit exertion in day-to-day activities but limit scholastic and other cognitive (e.g. mental) activities to allow the brain time to heal.  This means:

  • No text messaging

  • No video games

  • No homework

  • Possible limits on school attendance and activities

Conservative approach

Experts caution that, while an estimated 80 to 90% of concussions heal spontaneously in the first 7 to 10 days, children and adolescents may require a longer rest period and/or extended period of non-contact exercise than adults because children and teens experience a different physiological response to concussion than adults, take longer to recover, and have other specific risk factors. 

In practical terms, this more conservative approach means that:

  • Children and teens should not, under any circumstances, be allowed to return to practice or play until completely free of symptoms; 

  • No return to play on the same day as the injury, regardless of competitive level; and

  • "Modifying factors" take on more importance in the investigation and management of concussion 

Return to play guidelines

Return to play follows a six-step process:

 Rehabilitation Stage
  Functional exercise  Objective of stage
1. No activity
 Complete cognitive (e.g. mental) rest
 Recovery
2. Light aerobic exercise Walking, swimming or stationary bicycle keeping intensity less than 70% of maximum predicted heart rate Increase heart rate
3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer.  No head impact activities
 Add movement
4. Non-contact training drills
 Progression to more complex training drills, e.g. passing drills in football and ice hockey
 Exercise, coordination and use of brain
5. Full contact practice
 Following medical clearance, participate in normal training activities
 Restore confidence and assess functional skills by coaching staff
6. Return to Play
  Normal game play
  

 7 + days to recover

Generally, each step should take at least 24 hours, so that, assuming the athlete does not experience concussion symptoms at rest or with exercise at the current level, she will be able to return to sports in about a week's time.  If any post-concussion symptoms occur at any level, the athlete needs to drop back to the previous level at which she was symptom-free, and try to progress again after a further 24-hour period of rest has passed

Source: Concussion Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.

Revised and updated November 5, 2009