Return to Play Concussion Education Part 2

What is Return to Play? Part 2 Concussion Education

Last week, we talked about what a concussion is and what precautions to take if you suspect one. This week, we’re getting into the process of safely returning a concussed individual back to their normal routine. This blog post is NOT meant to replace clinical judgement but should be used as an educational tool for you to further understand the clinical process and treatment of a concussion.

Concussion testing and management is a quickly evolving process. What was practised a few years ago has greatly changed with the accessibility of technology and the realization that concussions are not exclusive to professional athletes.

Return to Play is a concept that slowly integrates an athlete, that has suffered a concussion, back into their routine sport. It’s a management plan that initially prescribes both physical and cognitive rest. Physical rest is often well understood by patients, but the cognitive rest is sometimes more difficult to understand and implement.

Physical rest means avoiding activities that may result in an increase heart rate or breaking a sweat; it is important that the activities do not trigger or worsen symptoms.

Cognitive rest involves avoiding cognitive activity that may trigger or worsen symptoms. In its extreme form, this includes no school attendance, no homework/school work, no video games, no cell phone time, no computer time, and no television.

REASONING: Both types of rests help to optimize healing by reducing the brain’s workload in the the acute post-injury phase.

King-Devick Test

The general guiding principle throughout the recovery is to minimize activity as much as possible to allow the brain to heal. With most concussions that become asymptomatic at around 14 days, it is crucial that both physical and cognitive rest be strictly monitored. However, being asymptomatic DOES NOT mean the brain has completely healed itself. The brain’s metabolic systems must normalize, which may take longer. If symptoms prolong themselves, it is important that the concussed individual participate in low-key social interactions with friends and family to prevent social isolation and/or depression and anxiety from the removal of daily activities.

Visual Tracking

The Zurich Consensus outlines a 6-step progression guideline that occurs when the concussed individual can rest without symptoms–however progression into consecutive stages is dependent on age, level of play, and prior medical history. That is why this program requires supervision under a trained healthcare professional since parameters of each program can be different from one another. Generally, each step should take 24h so that an athlete would ideally take 1 week to proceed through the full rehabilitation protocol (refer to chart). If any symptoms occur while in the stepwise program, the athlete will drop back to the previous asymptomatic level and try to progress again after a further 24h period of asymptomatic rest has passed.

We must reiterate that every case is different, and cases where clinical recovery falls outside of the expected window (ie. 10-15% of concussion symptoms last beyond 10 days) should be managed in a multidisciplinary manner by healthcare providers with experience in sports-related concussions.

If you have any further questions, please feel free to contact your Sheddon Therapist!

Zurich Guidelines

Rehabilitation StageFunctional Exercise at Each Stage of RehabilitationObjective of Each Stage
1. No ActivityComplete physical and cognitive restRecovery
2. Light aerobic exerciseWalking, swimming or stationary cycling. Keep intensity < 70% MHR; no resistance trainingIncrease HR
3. Sport-specific exerciseSkating drills in ice hockey, running drills in soccer; no head impact activitiesAdd movement
4. Non-contact training drillsProgression to more complex training drills, e.g. Passing drills in football and ice hockey; may start progressive resistance trainingExercise, coordination, and cognitive load
5. Full contact practiceFollowing medical clearance, participate in normal training activitiesRestore confidence and assess functional skills by coaching staff
6. Return to playNormal game playNormal game play



Master, C., et al. “The importance of “return-to-learn” in pediatric and adolescent concussion.” Pediatr Ann 41.9 (2012): 1-6.

McCrory, Paul, et al. “Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.” British Journal of Sports Medicine 47.5 (2013): 250-258.