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These guidelines are intended for implementation by Athletic Trainers, Athletic Directors and Coaches. Diagnosis of concussion and return to play decisions should be made by licensed physicians only. First aid should only be administered by trained individuals.

Important points

Physicians must be aware of the following important points when making return to play decisions in concussed athletes:

1. No athlete should be returned to play until they are symptom-free and their cognition has recovered.
2. Athletes with persistent symptoms or cognitive impairments should be referred for specialist neurological and/or neuropsychological evaluation.
3. All athletes should undergo a stepwise return to exercise before returning to play.

Return to play

The vast majority of concussions recover over 3-7 days, although some patients will take longer to recover. Referral to a neurologist or neurosurgeon with expertise in concussive injury is recommended for patients who exhibit persistent neurological or cognitive symptoms for longer than this.

For the majority of patients who recover within a week of concussion, return to play decisions are based on repeated evaluation in the days following the injury. There are three basic steps in the return-to-play decision making process:

1. Determine if symptoms have resolved.
2. Determine if cognition has recovered.
3. Rehabilitation and graded return to exercise.

It is important to emphasize that a qualified physician must supervise the management of a concussion and determine the timing of return to play.

1. Determine if symptoms have resolved

Patients should be evaluated until their symptoms have resolved. The evaluation should include specific reference to these symptoms and the patient should not proceed to the next step until he/she reports that he/she is symptom free.

 2. Determine whether cognition has recovered

The consensus of the First International Symposium on Concussion in Sport was that "neuropsychological testing is one of the cornerstones of concussion evaluation". Medical evidence suggests that recovery proceeds in a step-wise process for most patients, with symptom resolution occurring before cognitive resolution.

The next step in the process is therefore a formal cognitive evaluation. At this stage the patient should perform an ‘after injury' CogSport test, and the report should be e-mailed to CogSport for analysis. CogSport also includes a post-concussion questionnaire that summarizes the patient's symptoms at the time of testing, and also other useful information (time since injury, whether loss of consciousness occurred etc.).

The patient should not proceed to the next step until their cognition has recovered.

Although CogSport is designed to be highly sensitive to post-concussive cognitive impairments, false positive and false negative impairments are reported. These could be due to factors such as fatigue, feigned impairment and distraction. The possibility that these factors are affecting the athlete's performance should also be considered by the clinician.

Return-to-play decisions should not be based on CogSport results alone. Such decisions must also take into consideration the athlete's clinical signs and symptoms, history of concussion, the results of any other investigations undertaken (e.g., MRI or CT scans), and also the possibility that false-positive or false-negative impairments may be reported.

3. Rehabilitation and Stepwise Return to Exercise

The patient must be completely symptom free and have normal neurological and cognitive results before starting the rehabilitation program. This program includes a stepwise return to exercise, with gradual increases in exercise duration and intensity. The program is described in the box Return to Play Protocol.

With this stepwise progression, the patient should proceed to the next level only if symptom free at the current level. If any post concussion symptoms occur, the patient should drop back to the previous symptom free level and try to progress again after 24 hours. Although each step may take a minimum of one day, depending on the duration or recurrence of symptoms, proceeding through each step may take longer in some patients.