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Gradual Return to Play After Concussions Recommended

Exercise should only begin after period of cognitive rest and concussion symptoms clear

Return to play guidelines

Return to play after concussion should follow a six-step process:

 Activity  Objective
1. No activity
Symptom limited physical and cognitive (e.g. mental) rest (see above)
2. Light aerobic exercise Walking, swimming or stationary bicycle keeping intensity less than 70% of maximum predicted heart rate; no resistance training 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; may start progressive resistance training Exercise, coordination and use of brain
5. Full contact practice
Following medical clearance, participate in normal training activities
Restore confidence and allow coaching staff to assess functional skills
6. Return to play
 Normal game play


While many of the youth sports concussion safety laws passed by the states in recent years contain broad language allowing any "qualified health care professional" to make the return-to-play decision, studies show that many primary care physicians [10] lack the expertise required to make return to play decisions.  Because they have more training and experience in concussion diagnosis and management, certified athletic trainers, team doctors, and neuropsychologists are usually the best qualified to decide when it is safe for an athlete to return to play.


7 + days to recover

Generally, each step should take at least 24 hours, so that, assuming the athlete does not experience a reoccurrence of concussion symptoms at rest or with exercise as she progresses through the exercise program, she will be able to return to sports in about a week's time after symptoms have cleared.   

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.

The Model Policy and Guidance for Prevention and Treatment of Sports-Related Concussions and Head Injuries recently issued by the New Jersey Department of Education pursuant to that state's concussion safety law suggests that, 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 commencing the protocol.
  • 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. 
While not as conservative as the model concussion management policy proposed by the New Jersey Department of Education, California recently became the first state to mandate a minimum 7-day waiting period after a concussion before a return to sports for interscholastic athletes, and to require the successful completion of a graduated return-to-play exercise protocol supervised by a health care professional which can only begin once a student-athlete is no longer experiencing concussion symptoms.
According to data released in March 2016 by the National Athletic Trainers' Association, 44 percent of states now require that a graduated return-to-play protocol consisting of at least five steps (with no more than two steps occurring on one day) is implemented for athletes returning back to activity from a concussion, which is a 24 percent improvement from the 2014-2015 school year.  

Non-compliance is serious problem

In their desire to return to the playing field, some high school athletes fail to comply with return to play guidelines.  A 2009 study [4] by researchers at Nationwide Children's Hospital in Columbus, Ohio found that at least 40.5% and 15.0% of athletes who sustained concussions returned to play prematurely under the now-outdated American Academy of Neurology (AAN) and then current Zurich return-to-play guidelines.  

A 2011 study, [5] however, shows for the first time the important role computerized neuropsychological testing is playing in concussion assessment and return to play decisions. Athletes who had taken a pre-season, baseline ImPACT computerized neuropsychological test, and took the ImPACT test again after suspected concussion were less likely to return to play on the same day, and less likely to return to play within a week of their injury, than the three out of four injured athletes who did not undergo such testing.

The authors suggested three possible reasons:

  1. that the computerized tests are more reliable in guaging whether an athlete's cognitive functioning had returned to baseline than self-reporting by athletes of signs and symptoms (which, in the interest of a quick return to play, an athlete may downplay or fail to report altogether)(a hypothethesis which was confirmed in a more recent study; [6]
  2. that the use of such tests by those providing concussion management leads them to be more conservative in return-to-play decisions; and
  3. that neurocognitive testing is used more often in cases of severe concussions that require extended recovery times before return to play.

Post-exercise neurocognitive testing recommended 

A 2013 study [9] of concussed student-athletes who reported no symptoms and had returned to baseline on computerized neurocognitive tests taken before beginning the graduated return to sports protocol, found that more than a quarter (27.7%) exhibited declines in verbal and visual memory on the tests after moderate exercise. 

The findings prompted the study's authors, led by sports concussion neuropsychologist Neal McGrath, Ph.D. of Sports Concussion New England, to recommend that neurocognitive testing become an "integral component of the athletic trainer's post-exertion evaluation protocol and that student-athletes should not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on such post-exertion neurocognitive concussion testing."

"Given the unreliable nature of self-reported symptoms in athletes, a group typically motivated to return to play and minimize symptoms, the sensitivity of computerized neurocognitive testing to incomplete recovery and the importance of identifying any indicators that an athlete may not remain stable in his/her baseline functioning prior to return to contact sports action, post-exertion neurocognitive testing appears to be a logical tool to consider." 

"Our thinking," said McGrath, "is that since exercise is known to cause recurrence of symptoms in some athletes who may not be fully recovered, and since neurocognitive testing has been shown to reveal persisting cognitive deficits in athletes who say or feel that they are symptom-free, [6] any significant decline in post-exercise cognitive test scores for those athletes who have reached the point of feeling fully symptom-free, with resting neurocognitive scores that are back to baseline, would indicate that more recovery time is needed before returning to contact sports action. We would follow those athletes until their post-exercise neurocognitive test scores remain stable at baseline levels before clearing them to return to play." 

1. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.  Br. J. Sports Med. 2013:47:250-258.

2. Halstead, M, Walter, K. Clinical Report - Sport-Related Concussion in Children and Adolescents.  Pediatrics 2010;126(3):597-615.

3.  Meehan W, d'Hemecourt P, Comstock D. High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

4.  Yard EE, Comstock RD. Compliance with return to play guidelines following concussion in US high school athletes, 2005-2008.  Brain Inj. 2009:23(11):888-98.

5. Lincoln A, Caswell S, Almquist J, Dunn R, Norris J, Hinton R. "Trends in Concussion Incidence in High School Sports: A Prospective 11-Year Study"Am. J. Sports Med.accessed January 31, 2011 @http://ajs.sagepub.com/content/early/2011/01/29/0363546510392326.

6. 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 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012).

7. Moser RS, Glatts C, Schatz P. Efficacy of Immediate and Delayed Cognitive and Physical Rest for Treatment of Sport-Related Concussion. J Pediatrics DOI: 10.1016/j.jpeds.2012.04.012 (in press).

8. Majerske CW, Mihalik JP, Ren D, Collins MW, Reddy CC, Lovell MR. et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance.  J Athl Tr. 2008;43:265-274.

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.  Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric Providers' Self-Reported Knowledge, Practices, and Attitudes About Concussion. Pediatrics 2012;130(6). DOI: 10.1542/peds.2012-1431)(published online ahead of print)(accessed November 19, 2012)

11. Howell D, Osternig L, Van Donkelaar P, Mayer U, Chou L.  Effects of Concussion on Attention and Executive Function in Adolescents.  Med Sci Sports Exer. 2013;45(6):1023-1029.

12.  Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics 2014;133(2):1-6. 

13. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sport: postconcussive activity levels, symptoms, and neurcognitive performance. J Athl Tr. 2008;43(3):265-274.

14. McGrath N. Supporting the student-athlete's return to the classroom after a sport-related concussion.  J Athl Train. 2010;45(5):492-498.   

Most recently updated March 17, 2016