Return to Play
CRM: Return to Play
Concussion Recognition & Management
Module 5 Management

Return to Play

Back in the Game

Mention of any specific health care facility or organization in the videos reflects an individual’s specific experience and is not intended as an endorsement from this site.

child kicking ball, Return to Play
To minimize the risk of re-injury, it’s recommended that the following criteria are met before a patient begins a Return to Play Progression:
  • No academic adjustments or accommodations are in place or needed.
  • The patient is asymptomatic at rest and exertion.
  • The patient has a normal neurocognitive score when compared to the baseline (if available), presumed baseline, or normative standard. (Testing shows that an individual who is not neurocognitively normal may be symptomatic.)
  • The patient has normal Balance / Postural Stability scores compared to baseline (if available), presumed baseline, or normative standard.
As this course has previously emphasized, there must be no same-day Return to Play for an athlete diagnosed with a concussion or an athlete suspected of having a concussion who has not been evaluated by health care professionals. No matter what, once an athlete has returned to baseline, he or she must undertake a multistep progression.

The Return to Play Progression follows this general pattern:
Clearance to Start Return to Play Progression, Monitoring, Management Team Approval

State of Nebraska Seal

Return to Play Clearance

According to the Nebraska Concussion Awareness Act, a licensed health care professional must give written clearance to Return to Play. The law says:
"Such student shall not be permitted to participate in any school supervised team athletic activities involving physical exertion, including, but not limited to, practices or games, until the student (i) has been evaluated by a licensed health care professional, (ii) has received written and signed clearance to resume participation in athletic activities from the licensed health care professional, and (iii) has submitted the written and signed clearance to resume participation in athletic activities to the school accompanied by written permission to resume participation from the student’s parent or guardian."

Nebraska Revised Statutes, Sections 71-9101 to 71-9106

Clearance to Return to Play Letter

This course recommends being very clear in your letter. Your initial role is to provide clearance for the progression to Return to Play. That is not the same as clearance to return to full activities and competition. You need to set the standards and steps for what the patient is allowed to do at what stage in the progression, based on symptoms and response to treatment, with continual monitoring and assessment.

A Clearance to Return to Play letter is not a carte-blanche license for the child to dive immediately full force into all activities. Be clear about what you’re clearing.
Example of Nebraska Sports Concussion Network
Written Clearance / Permission Form
licensed health care professional signing clearance letter

child meditating and then walking in garden

Return to Play Progression

This course recommends that an athlete obtains a Clearance to Return to Play letter before undertaking Stage 2 in the Return to Play progression. That is a conservative approach, but conservatism is warranted given the risk of re-injury. If there are no problems along the way, the patient may progress from one step to the next and must complete all steps. The standard for high school is about one step per day.

Return to Play Progression: 1 rest 2 walking 3 skating 4 hockey exercise 5 hockey practice 6 winning game


Rehabilitation Stage

Functional Exercise
at each Stage of Rehabilitation

of each Stage

1. No Activity
  • Symptom-limited physical and cognitive rest.
2. Light Aerobic
  • Walking, swimming, or stationary cycling, keeping intensity < 70% maximum permitted heart rate.
  • No resistance training.
Increase HR.
3. Sport-Specific
  • Skating drills in ice hockey, running drills in soccer.
  • No head impact activities.
Add movement.
4. Non-Contact
     Training Drills
  • Progression to more complex training drills, (e.g., passing drills in football and ice hockey).
  • May start progressive resistance training.
Exercise, coordination, and cognitive load.
5. Full-Contact
  • Following medical clearance, participate in normal training activities.
Restore confidence, and assess functional skills by coaching staff.
6. Return to Play
  • Normal game play.
The 4th International Conference on Concussion in Sport Zurich Statement
Detailed Return to Play Progression
ImPACT, UPMC Sports Medicine Concussion Program Guidelines for Post-Concussion Rehabilitation
Borg Rating of Perceived Exertion Scale
Use this scale as a way of measuring physical activity intensity level to help you evaluate a patient’s readiness to Return to Play.

Start the Return to Play Progression with a letter clearing the patient to proceed. Others on the care team may monitor. No matter who is involved, the patient has to progress. If symptoms reoccur or don’t clear up, the injured child has to return to see a licensed health care professional. It’s a clinical preference how often the patient should return to the office for reassessment. Many providers only want to hear back if the symptoms persist or other problems occur.

When the patient has completed the monitored Return to Play Progression, the patient can be given approval for full contact play by a licensed health care professional. In cases where logistics make multiple trips unfeasible, some licensed health care professionals collaborate with the school professionals to provide the needed assessments and documentation.

An Example of a Return to Play Progression

Even with appropriate behavioral management, some students continue to experience significant symptoms after the two-week mark. Module 6 of this course will address complex concussion management in depth. At that point, your management team may expand beyond the initial group (you, the patient, the family, and the school staff) to include other licensed health care professionals who bring special expertise to the case.
Module 5 Management

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