Orlin & Cohen - Sports Medicine Tips

Date: 4/16/2020
Posted by: Karen Wohlrab
Authors: Leslie Ellis, MD and John Meahan, A.T.C 

Concussion Return to Play (RTP)

Concussion Review
A concussion is a type of traumatic brain injury (TBI) that occurs from a direct or indirect blow to the head or neck. Concussions occur when the brain reacts to the force from the blow to the head and causes the brain to move rapidly back and forth. The result of the rapid movement of the brain in the skull causes a change in ionic imbalance and metabolism. These changes can cause a temporary impairment in brain function. Symptoms that come along with this impaired brain function can include but are not limited to; headache, nausea, dizziness, light sensitivity, tinnitus, impaired balance, depression and short term memory loss. Concussions can occur in both males and females of all levels of sport, mostly occurring in contact and collision activities.
Post Concussion Management
Following a concussion diagnosis an athlete should be removed from their sport and all physical activities until cleared by a physician. Each case is unique and should be treated as such that should not be graded on how the injury occurred or the degree of symptoms. Patients should be instructed to implement physical and cognitive rest. Physical rest is refraining from any strenuous physical activity and also getting adequate sleep. Light aerobic activity that does not provoke symptoms (stationary bike, walking) can help expedite the time to return to normal function. Cognitive rest is meant to limit academic work, bright rooms, and to limit use of screen time (phone, computer, television). The goal of cognitive rest is to limit symptoms, one should tailor their cognitive rest based on their symptoms and limit activities that incite previous or new symptoms. Subsequent to obtaining clearance to return to sport and activities from a physician, athletes should participate in a return to play protocol.
Return to Play (RTP)
Following a physician's clearance to return to activity a gradual progression in activity is usually done over a 6 stage process with 24 hours in between each stage. Table 1 shows the separate stages in the return to play process. Patients should be symptom free for 24 hours before beginning the process.

Table 1 - Gradual Return to Play






Symptom free daily living activities

Limited to none

Return to daily school/home routine


Light Aerobic Exercise <70% age predicted max Heart rate

Stationary Bike, Walking on treadmill

Increase Heart Rate


Sport Specific Exercise

Non-contact agility drills tailored to sport.

Imitating movements done in practice


Non-contact practice

Non-contact training with others. Resistance exercise.

Coordination and increased thinking


Full contact Practice

Normal Training Activities

Increase confidence and assessing functional skills


Game or Contest

Full return to sport with no restrictions

Return to sport.


After completing each stage, the patient should be assessed if any of the activities in each stage brought upon new or previous symptoms. If the patient is asymptomatic, they may move on to the next stage following a 24 hour period. If at any stage the patient experiences new or previous concussion symptoms they should stop activity.  They can return to the protocol if they are symptom free for 24 hours. They will begin the protocol at the stage below the stage where they became symptomatic. For example; A patient finishes stage 4 but experiences headaches, nausea and dizziness, after a 24 hour asymptomatic period he or she returns and begins stage 3.
Concussions are a growing concern among athletes in all levels of sport. A gradual return to play protocol ensures that athletes complete an increased level of activity over time. A concern of premature return to play by athletes is second-impact syndrome which occurs after a second impact while the patient is still symptomatic from a previous injury to the head or body. The condition is characterized by diffuse cerebral swelling with catastrophic deterioration. The main goal is to have the athlete return safely without any recurring symptoms and avoid second impact syndrome


1. Guskiewicz KM, Bruce SL, Cantu RC, et al. National athletic trainers’ association position statement: Management of sport related concussion. J Athl Train. 2004;39(3):280–297
2. Broglio SP, Cantu RC, Gioia GA, et al. National athletic trainers’ association position statement: Management of sport concussion. J Athl Train. 2014;49(2):245–265
3. The University of the State of New York The State Education Department Office of Student Support Services. Guidelines for Concussion Management In Schools 2018 Retrieved from: http://www.p12.nysed.gov/sss/documents/ConcussionManageGuidelines.pdf