Concussion Protocol Return to Play: Parents and Coaches Guide

Reading Time: 7 minutes
  • How Concussions affects a significant number of adolescents in organized sports, with 1.8 to 3.6 million cases annually.
  • What are the six clinical classifications of concussions, including cognitive/fatigue, vestibular, ocular, post-traumatic migraine, cervical, and anxiety/mood concussions.
  • Why a proper concussion protocol involves several stages in which physical therapists play a crucial role in ensuring athletes are ready to safely resume sports activities.

If you had to guess what injury affects between 1.8 and 3.6 million adolescents a year, what’s your call? Here’s another hint – it’s an injury that makes up 6-7% of total injuries in organized sports, with increased numbers in contact and collision sports.

Drum roll please… we’re talking about concussions.

Concussions are the talk of the sports town – and, sometimes, not in the best way. Fortunately, we know a lot more now about concussions than we used to. Let’s get familiar.

The old way of thinking used to be that there were mild, moderate, and severe concussions. Now that concussion knowledge has expanded, we know that there are six clinical classifications. This helps to better treat and manage concussions on an individual basis, rather than on a generic timeline.

So, what are the six different types of concussions and how do they differ?

1. Cognitive/Fatigue

An athlete suffering from this type of concussion often struggles with mental tasks, like school or homework. This can include complex subjects, like math and science, and long, extended school days. Feeling fatigued is inevitable – to no surprise.

If your athlete has a cognitive/fatigue concussion, he or she may have:

Difficulty concentrating

Increased perceptibility to distraction

Trouble remembering things

Decreased ability to multitask

2. Vestibular

Vestibular concussions affect balance, motion, and vision. An impaired vestibular system can cause deficits in:

Interpreting motion

Coordinating head and eye movement

Balanced vision with head movement

3. Ocular

Visual tasks become more difficult with ocular concussions. Your athlete may struggle with reading long paragraphs or looking at a computer screen.

4. Post-Traumatic Migraine

This type of concussion is associated with – you guessed it – migraines. Headaches that are accompanied by nausea and sensitivity to light are some key indicators.

5. Cervical

If there is a cervical component to your athlete’s concussion, then he/she will likely feel pressure or stress in the neck, spine, or spinal cord. Forward shoulder posture can increase that feeling and ongoing headaches can develop as a result of cervical concussions.

6. Anxiety/Mood

Anxiety or mood concussions lead to difficulty turning off your thoughts and excessive worry. Your athlete’s social skills may be affected but avoiding those routine interactions can actually make the concussion worse.

How To Tell If Your Athlete Has a Concussion

First of all, it’s important to note that a concussion is not just a football injury – it can happen to any athlete. Like we stated earlier, we know a lot more now about concussions than we used to. One of those things is that there are two common mechanisms of injury.

Concussions can happen as a result of impact, yes. However, they can also result from non-impact. Non-impact concussions are usually rotational injuries. This means the athlete’s head may never make contact with the ground, a ball, another head, or anything of the sort.

Regardless of the mechanism of injury, if your athlete is suspected of having a concussion, then he or she must be immediately removed from the game, practice, or event and checked out by a physician.

Signs of Concussions (observed by Coach, Parent/Guardian, or Healthcare Professional)

  • Appears dazed or stunned
  • Forgets plays or demonstrates short term memory difficulties (e.g. unsure of game, opponent)
  • Problems with balance, coordination, concentration, and attention
  • Answers questions slowly or inaccurately
  • Demonstrates behavior or personality changes
  • Unable to recall events prior to or after the hit or fall

**Loss of consciousness may or may not occur and is not always associated with the injury, although it can be. Less than 10% of people who suffer from a concussion will experience loss of consciousness.

Symptoms of Concussion (reported by the athlete):

  • Headache
  • Feeling tired
  • Feelings of sluggishness or fogginess
  • Difficulty with concentration, short term memory, and/or confusion
  • Mood changes
  • Dizziness or balance problems
  • Motion sensitivity
  • Nausea or vomiting

If your athlete develops a worsening headache, seizures, visual disturbances, numbness/tingling, or weakness in extremities, then it is critical to be evaluated by a physician as soon as possible.

Remember that these signs and symptoms can come on rapidly or they can be delayed. Signs and symptoms are known to develop over a 48-hour period. This is due to the fact that concussions are a chemical disturbance in the brain rather than a structural injury.

Short- and Long-term Effects of Concussion

The good news is, most concussions are only going to affect your athlete for a short period of time. The majority of cases resolve spontaneously – with proper treatment – and do not have any long-term consequences.

But, it is imperative that your athlete receives proper medical care to avoid any long-term effects of concussions. Education, reassurance, and appropriate accommodations and treatment are the key to success when it comes to concussion recovery.

  • Proper education on what a concussion is (and is not), along with ways to limit cognitive and physical activity in the first few days, ensures the most rapid recovery possible.
  • Athletes tend to worry about what happens next after a concussion. Reassurance in recovery will help you with the anxiety that typically accompanies the diagnosis.
  • Appropriate school accommodations and treatment must go hand in hand with the type of concussion you have sustained.

Long-term effects of concussion are associated with issues that linger for weeks or months after the initial injury. Your athlete may experience more headaches than normal or suffer from concussion symptoms that weren’t there before the injury.

Most of the time, concussion symptoms can resolve with proper treatment, even after the fact. They are bound to hang around without such. This is part of the reason it’s so important to be evaluated if you believe that your athlete may have a concussion.

Concussion Protocol for Return-to-Play

Handling the athlete’s return to play is not a new practice, and it has received a considerable amount of attention over the past few years. Thankfully, now that we understand more about the injury, experts are able to have a management system in place to quickly assess, treat, and return athletes to the game as quickly as possible.

You may be curious as to why there is such an importance placed on concussion protocols for return to play. Admittedly, there are good reasons for this. Without structured, research-backed concussion protocols in place, athletes are at risk for longer recovery times or potential long-term consequences. Moreover, athletes who fail the return-to-play concussion protocol or go back too soon are at serious risk of getting another concussion, worsening symptoms, or an injury to the lower body.

Therefore, to avoid these negative consequences, athletes must be taken through a full return-to-play concussion protocol and receive clearance from a qualified physician. But returning to games or practices is not only about being free from symptoms. Your athlete must meet a set of criteria, known as a Concussion Protocol Return to Play (RTP), which include:

1. No symptoms at rest

2. Normal neurologic exam

3. Normal neurocognitive test results

4. No symptoms with physical activity

Your athlete’s physician will check for requirements 1-3. However, making sure your athlete is symptom-free during physical activity (requirement 4) involves putting the athlete through six physical return-to-play stages. They are outlined below in greater detail.

Physical Return-to-Play Concussion Protocol Stage 1: No Activity

This stage focuses on giving the athlete a few days to rest from both physical and cognitive activities. The main objective during Stage 1 is a resolution of symptoms so that you can move on to the next step.

At this point, the athlete will be using any accommodations that have been given and potentially even going to vestibular therapy as a tool for recovery. Vestibular therapy can be crucial to help athletes deal with dizziness, nausea, and balance problems.

Physical Return-to-Play Concussion Protocol Stage 2: Light Aerobic Exercise

The goal for Stage 2 is to increase one’s heart rate. Athletes should not expect to exert themselves too much at this point in time.

Physical Return-to-Play Concussion Protocol Stage 3: Sport-Specific Activity

Now that the athlete’s heart rate has slightly increased with activity, adding sport-specific movement is the next step. Aerobic exercise that is similar to your athlete’s sport and resistance training are introduced at this point.

Physical Return-to-Play Concussion Protocol Stage 4: Non-Contact Training

After completing the sport-specific activity stage, the athlete will progress to non-contact practices with the team. The goal here is to increase exercise, coordination, and cognitive load while reintroducing competition – with no contact.

Physical Return-to-Play Concussion Protocol Stage 5: Full-Contact Practice

With the successful completion of Stage 4, your athlete can move on to full-contact practices. This means you’re at a normal activity level and should increase your confidence in returning to play 100%.

Physical Return-to-Play Concussion Protocol Stage 6: Return to Competition

The final stage of the athlete’s physical return to play concussion protocol is the reintroduction to gameplay. Once the athlete has officially returned to a game, he or she has graduated from the Concussion Protocol and is good to go!

A Physical Therapist’s Role in Concussion Protocol for Return-to-Play

It should come as no surprise that physical therapists can play a large role in the concussion protocol for return-to-play, especially during the graded physical return. Physical therapists are well suited to take your athlete through a safe, gradual return-to-play protocol to ensure that he/she is truly ready to get back on the field, ice rink, or court.

Similarly, physical therapists, in addition to team physicians, athletic trainers, and school nurses, have a responsibility to report injuries (like concussions) to parents, coaches, and other members of the coaching staff. Physical therapists who help with sideline management at sporting events may be called upon to perform quick screening tools if a concussion is suspected.


Concussions can be scary for an athlete. Though there are still unknowns about concussions, what we do know now has led to extremely successful treatment. And with proper evaluation and diagnosis, along with individualized treatment, rapid and complete recovery is possible.

At Myokinetix, a premiere physical therapy clinic in Morris County, the doctors of physical therapy are bonafide experts when it comes to returning from sports injuries. Your athletes are safe in their hands, and you can feel confident in knowing that your athlete will be ready for competition. Check out our full list of services here and give us a call to learn more about the Myokinetix Return to Play Concussion Protocol.

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