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Five Stages for Concussion Return-to-Play

When it comes to dealing with a student-athlete and a concussion, the first concerning questions include regaining a routine at school and resuming sports play. Whether the student sustained a concussion playing sports or after being involved in an accident, using a step process to return-to-learn and return-to-play can help avoid delaying the student’s return to a full workload.


Concussions should be evaluated by a physician, athletic trainer, or other medical professional who has experience in dealing with concussions as the exact course of action will depend on what that particular student needs. Initially, there is a rest phase of 2-4 days where the goal is to allow the body to start to heal itself by minimizing cognitive activity/academic workload and prevent deconditioning. Staying home from school should be considered if the symptoms are severe including the avoidance of nonessential screen time such as video games or cell phone use while the student is home. Using the computer for school work is ok, as long as it is done in short intervals of around 15 minutes at a time with breaks as needed. Physically, students should be encouraged to stretch and walk daily as symptoms allow. Deconditioning can set in rapidly and simple stretching and walking exercises may help minimize the effect of relative inactivity.

Understanding that the brain needs immediate rest is well accepted but reentry into school is a more difficult decision to make. Parents and students question us about when is it too early or too late since it is a hard decision to make as academic stress increases each year. Generally, a student can consider attending half days when listening, light reading, and exposure to light can be tolerated for 30 minutes. This doesn’t mean they have to be symptom-free, just that they can tolerate it. While at school, breaks should be taken as needed and classes should be avoided that could worsen the symptoms such as music or band. The goal in this phase from an academic standpoint is to allow the brain to begin light to moderate cognitive work without falling too far behind or making symptoms worse. Homework can be done in 15-30 minute intervals at first and increased over time but no work should be automatically excused. It’s important to create a schedule that will allow the student to make up assignments at a later date while staying on top of those subjects that build off the information each week such as math and foreign languages. Working with the school’s guidance counselor, nurse, athletic trainer, or ideally a combination of all three is extremely important at this stage.


When the student can attend full days of school and symptoms are minimal, they can consider increasing physical activity past the walking and stretching phase. Light to moderate aerobic conditioning while introducing resistance training in the form of resistance bands, light dumbbells, or some exercise machines for a total of 20-30 minutes can be very useful in getting the student out of the “sluggish feeling” they’ve been experiencing. Treadmill, stationary bike, elliptical trainers, resisted band exercises, and lunges are all examples of exercises in this second stage. Once the student is symptom free and has full academic tolerance, meaning the student is able to do homework and take notes, even if not fully caught up, he or she can progress to the third stage.


Students can expect to gradually increase the amount of academic work as they are being reintroduced to normal academic activity as symptoms improve. They should be attending school full time at this point with a goal of moderate to high cognitive activity while avoiding worsening of the symptoms. If symptoms start to worsen with increased cognitive load, it is not dangerous to the brain but can delay the symptoms going away completely. Thus, it is still important to monitor the completion of make-up work while also monitoring the exercise load that the clinician has prescribed until the student has returned to full academics and all make-up work is finished.

Usually at this stage the student can begin running, jumping, plyometrics, and challenging balance exercises but still must avoid maximal exercises. Generally, any environment is ok for exercise as long as it does not pose an inherent increased risk of contact with a goal of 25-35 minutes of cardio and strength training each time. Exercises such as jogging, free weight exercises, half speed agility drills, and non-contact non-risk activities (ice skating, stick handling, light ball kicking, batting cage work) are usually introduced at this stage, being careful to avoid increasing the symptoms. One can proceed onto stage 4 of the exercise progression after several days of success at this stage and when no academic adjustments are needed like extra time for tests or homework.


Stage 4 of the exercise progression is often where people think that return-to-play protocols start because it involves non-contact physical training and sport specific activities and drills. Exercises are performed at maximum intensity and can range from 35-45 minute sessions each day. The student should stay in this stage until the treating physician has provided clearance to fully return to sport in stage 5. A neurocognitive test like the ImPACT test is often performed at this point to ensure that the brain is fully recovered and they are able to resume contact activities. These sport specific programs are typically led by team athletic trainers or qualified coaches and include practice and game intensity level activities. It is important that at least two practices are completed before participating in games to ensure that the athlete is ready for the physical and cognitive challenges of game play.


Stage 5 is the graduation of the return-to-play protocol and involves the student  performing all of his or her desired activities without restrictions. Although it takes longer than anyone would like, understanding and following a step-by-step return-to-play program can decrease the amount of anxiety and frustration a student-athlete experiences while getting back on the field and in the classroom.

For more information about our concussion return to play or our concussion prevention programs, click here.

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