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The Six Pillars of Concussion Risk Management: The MomsTEAM Approach

Pillar Five: Cautious Return To Play

Return to play (RTP) after a child or teen suffers a sport concussion is a six step, exercise-limited process [1] which should proceed slowly and err on the side of caution in order to allow the brain time to fully heal:

1. No activity (symptom-limited physical and cognitive rest)(Pillar Four). When a student-athlete is no longer reporting concussion symptoms or receiving academic accommodations, and performing at or near his pre-injury baseline on all post-concussion tests (e.g. neurocognitive, balance, vision ), he may proceed to Step 2.

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 most 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

Caution urged

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.

Experts nevertheless 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. [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. [7]

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 [8] 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 [9] 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.

Pillar Six: Retirement​

It might seem strange to have retirement as the sixth and final pillar of the Six Pillars, but is included for a very important reason: when all else fails, when an athlete has suffered one or more concussions, and the risk of long-term injury simply becomes too high, the only step left to prevent further brain damage is to stop playing contact and collision sports (as one of the Newcastle High School players ends up doing).

Medicine has not yet figured out how many concussions is too many. The number that leads to permanent deficits in memory, concentration, and other cognitive processes, and/or that increases the risk of dementia and other problems later in life, is likely different for each athlete.


Several factors will likely influence a recommendation to an athlete to consider retiring from contact or collision sports, [1,10,11] including:

  • Number of concussions: Contrary to popular belief, there is no magic number of concussions that disqualifies an athlete from further participation in contact or collision sports. The number of concussions is a factor, but only one. [1,10,11]
  • Concussions occurring with less force. For some athletes, as the number of concussions rises, the force required to produce a concussion seems to decrease. When an athlete reports developing concussion symptoms after a seemingly minor blow to the head (such as an accidental blow to the head by the arm of an opponent or friend), such a sign is concerning, and will prompt a sports concussion specialist to discuss retirement with the athlete. [1]
  • Slower recovery. Most athletes recover from concussions quickly, in a matter of days to weeks. In high school-aged athletes, nearly 85 percent will be symptom-free within one week of their injury. For some athletes, however, the recovery time is much longer, lasting weeks to months. For others, they recover from their first few concussions quickly, but as they suffer more concussions, the recovery time increases, lasting weeks to months, or in some rare cases, longer than a year.
  • More pronounced cognitive losses. After a concussion, many athletes lose some cognitive function, e.g. their ability to think, remember, concentrate, and reason, which they regain as they recover, and which is a prerequisite to return to play (Pillar Five). For some athletes, the cognitive losses they experience at the time of injury increase with the number of concussions, with their memory, reaction time, and the speed with which they process information (all of which can be measured through pen-and-pencil or computerized neurocognitive testing), becomes much worse. [10,11]
Even without the presence of these concerning factors, there remains some risk, of course, from continued participation in contact or collision sports after concussion, with increased risk of a second concussion.licated family decision​

For most athletes, retiring from contact or collision sports has a major impact on their lives. For elite high school and college athletes trying to make it to the pros, it means giving up their dream.

Even for athletes at the high school level and younger, much social activity, self-identity, and enjoyment comes from sports participation, which, studies show, have many benefits for both boys and girls. The importance of such participation is often underestimated by clinicians, parents, teachers and other adults.

Often, when an athlete stops playing contact and collision sports, they lose the friends they spend time with before practice, while dressing for sports, stretching, warming up, after practice, while changing and showering, and on the bus ride to games. Not being around during these times means they miss out on conversations, jokes, the latest gossip, and the discussions that make people friends. This can be quite devastating to the athlete.

The decision to retire should be made jointly, after long discussion between the athlete, the athlete's family, other people important to the athlete (e.g. coach) and the team involved in the athlete's care, including the physician, neuropsychologist, nurse practitioner, and other members of the care team, and takes place over a series of visits lasting weeks to months.

For those young athletes who do not seek to play professional sports, or who do not have a realistic chance of doing so, most will assume less risk, and will retire from high-risk sports after fewer concussions than prompt an athlete who earns their living by playing professional sports to retire.

Ultimately, athletes make the decisions themselves, and only in very rare cases will a doctor refuse to allow an athlete to return against his or her wishes, and, even then, they are encouraged to seek a second opinion. [11]

Brooke de Lench is Executive Director of MomsTEAM Youth Sports Safety Institute, Founder and Publisher of MomsTEAM.com, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins), and the Producer and Director of  The Smartest Team: Making High School Football Safer, a PBS documentary about implementation of the Six Pillars concussion risk management program by the high school football program in Newcastle, Oklahoma.


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3. SCAT3. Br J Sports Med 2013;47:259 (full pdf can be accessed without charge at http://bjsm.bmj.com/content/47/5/259.full.pdf )

4. Child-SCAT3. Br J Sports Med 2013;47:263 (full pdf can be accessed without charge at http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/JSM/A/JSM_23_2_2013_02_14_MCCRORYY_200872_SDC3.pdf)

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7. Moser R. Ahead of the Game: The Parents' Guide to Youth Sports Concussion (Dartmouth College Press 2012), p. 102.

8. 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)

9. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Inj. 2013;27(1):103-113.

10. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)

11. Meehan WP, Kids, Sports and Concussion (Praeger 2011). 

12. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

13. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

14. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

15. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM.  Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives.  Brain Injury 2013;27(7-8):878-886.

16. McGuine T, Brooks A, Hetzel S, Rasmussen J, McCrea M. "The Association of the Type of Football Helmet and Mouth Guard With the Incidence of Sport-Related Concussion in High School Football Players." Presentation Paper AOSSM, July 13, 2013.

17.  Mihalik JP, Blackburn JT, Greenwald RM, Cantu RC, Marshall SW,Guskiewicz KM. Collision type and player anticipation affect head impact severity among youth ice hockey players. Pediatrics. 2010;125:1394-1401.

18. Gregory S. "Neck Strength Predicts Concussion Risk, Study Says" (http://keepingscore.blogs.time.com/2013/02/21/study-neck-strength-predic...)(accessed February 22, 2013), citing Comstock R.D. High School Sports-Related Injury: Recent Trends and Research Findings. Presented at the National Youth Sports Safety Summit, Washington, D.C., February 5, 2013.

19.  Broglio SP, Martini D, Kasper L, Eckner JT, Kutcher JS.  Estimation of Head Impact Exposure in High School Football: Implications for Regulating Contact Practices.  Am J Sports Med 2013;20(10). DOI:10.1177/036354651302458 (epub September 3, 2013).

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21. Mueller, F, Colgate B. Annual Survey of Football Injury Research 1931-2011, National Center for Catastrophic Sports Injury Research; February 2013. (accessed at http://www.unc.edu/depts/nccsi/2012FBInj.pdf

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25.  Research paper, "Effect of New Rule Limiting Full Contact Practice on Incidence of Sport Related Concussion in High School Football Players."  McGuine TA, Hetzel S, Brooks MA. Presented at American Academy of Pediatrics National Conference and Exhibition. October 24-27, 2015, Washington, D.C.

26. Research Paper. "The Reporting of Concussions Among High School Football Players, an Updated Evaluation." Minor JL, MacDonald J, Meehan WP. Presented at American Academy of Pediatrics National Conference and Exhibition, Washington, D.C. October 24-27. (most recently accessed October 23, 2015 at https://aap.confex.com/aap/2015/webprogrampress/Paper32146.html)

Most recently revised November 7, 2015