A concussion is a traumatic brain injury (TBI) that temporarily disrupts normal brain function, resulting from a blow to the head or body that causes the brain to rapidly move inside the skull. The effects are typically short-lived, manifesting as headaches, dizziness, difficulty concentrating, or problems with balance or sleep. Returning to play before the brain has fully healed is dangerous because it leaves the brain vulnerable. A second impact, even a minor one, before recovery is complete can lead to brain swelling, known as Second Impact Syndrome, which carries a high risk of causing permanent disability or death.
Initial Clearance and Symptom Resolution
Following a concussion, the first step is a period of complete physical and cognitive rest. This initial rest period, often recommended for the first 24 to 48 hours, allows the brain to begin recovery without being strained by physical exertion or demanding mental tasks. Activities requiring significant concentration, like schoolwork or excessive screen time, should be strictly limited.
Before any physical activity resumes, the individual must be entirely free of all concussion-related symptoms, including headaches, nausea, or sensitivity to light. This symptom-free status must be maintained for at least 24 hours at rest. Medical clearance from a healthcare professional specializing in concussion management is mandatory before progressing. This assessment ensures that underlying issues, like impaired reaction time or balance deficits, are not present despite the absence of subjective symptoms.
The Graduated Return-to-Play Protocol
The process of returning to play is a structured, sequential series of stages known as the Graduated Return-to-Play (GRTP) Protocol. This protocol is designed to safely increase physical and cognitive stress on the brain incrementally, ensuring the athlete can tolerate each level of activity without symptoms returning. Each stage must take a minimum of 24 hours, meaning the shortest possible recovery timeline, assuming no setbacks, is approximately one week after symptoms have resolved.
The structured progression is managed by a medical professional and requires the athlete to remain symptom-free throughout every 24-hour stage:
- Stage 1: Light aerobic exercise (walking, swimming, or stationary cycling), keeping the heart rate below 70% of the estimated maximum.
- Stage 2: Sport-specific exercise (running drills or skating), avoiding activities that involve head impact.
- Stage 3: Non-contact training drills involving complex movements, coordination, and light resistance training to challenge balance and cognitive function.
- Stage 4: Regular non-contact training drills at full speed, including heavy non-contact activities and a regular weightlifting routine.
- Stage 5: Full-contact practice, resuming normal training activities and assessing tolerance of contact.
- Stage 6: Return to full competition, authorized after completing full-contact practice without symptom return and receiving final medical clearance.
Recognizing Setbacks and When to Stop
During the Graduated Return-to-Play Protocol, athletes and coaches must be vigilant for symptoms that signal a setback, such as a returning headache, dizziness, nausea, or increased light or noise sensitivity. The re-emergence of symptoms indicates that physical exertion has exceeded the brain’s current capacity for recovery.
If symptoms return at any point during the GRTP protocol, the athlete must immediately stop the activity. The mandatory rule is to revert to the previous stage where the athlete was symptom-free, or return to complete rest. The athlete must then maintain a symptom-free status for a minimum 24-hour period before attempting to re-start the protocol at that previous stage. Immediate reporting of any returning symptoms to the medical team overseeing the recovery is necessary to ensure proper management.