Graded return to play for adults

Each concussion should be assessed on a case-by-case basis.However, regardless of the extent or nature of the concussion there is a need for immediate cognitive and physical rest.Understanding of concussion is evolving but neurophysiology suggests that the brain does not begin to recover for some days after the initial insult and that there is an increased risk for some time after the initial injury.A healthcare professional trained in the management of return to play and head injuries must supervise the graded return to play (GRTP).Where there appears to be any delay or complication, the GRTP must be undertaken alongside a doctor with specialist training in head injury management and return to play.All concussions must be discussed with the club Chief Medical Officer, appropriate specialist or doctor and the player must undergo a face-to-face review by a healthcare professional trained in concussion management.All symptoms need to be absent for 24 hours before simple cognitive and physical activities can be undertaken.Graded steps of gradual increase in activity must be accompanied by a 24-hour window to check for further symptoms or signs.To achieve the last two levels as identified in the below table, the player needs a 24-hour window for each level and this therefore means no further return to a full training situation for six days.

Graded return to play for children and adolescents

Children’s/adolescents’ (five to 19 years) brains are still developing and as such, all children and adolescents require additional caution in the management of head injuries. The child and adolescent brain is still improving its learning potential and thus it is imperative that the cognitive function is restored as a priority before any return to sport is considered. This, in addition to other differences in physiological responses and specific risks, demands a more conservative return-to-play approach. It is appropriate to extend the amount of time of asymptomatic rest and/or the length of the graded exertion in children and adolescents. All children under the age of 12 should be assessed using the Child SCAT3 (PDF).The priority in the management of return to play in any child or adolescent must be a successful return to normal school function before they can return to sport.It is likely that in this case the return-to-play period is 23 days.There are specific additional return-to-school guidelines, which include extra-time for assignments/exams, quiet study areas, increased breaks, rests and a reduction in stressful situations.All return to play should be subject to appropriate medical clearance and any worsening symptoms and signs, or failure to recover as expected, requires further specialist referral. 
Staged rehabilitation 
Functional exercise at each stage of rehabilitation 
Stage objective 
No activity for 24 hours 
Complete rest: physical and cognitive
Needs to be symptom free for a minimum 24-hour window  
Light aerobic exercise 
Walking, swimming or stationary cycling, keeping intensity mild to moderate (i.e. not out of breath) Less than 70% maximum permitted heart rate. Duration should not exceed approx. 20-30 minutes. Avoid resistance exercises 
Increase exertion/heart rate
Sport-specific exercise 
Simple fielding (catching/throwing), low-key batting. Bowlers bowl to empty net at around 50% avoiding exposure to head injury risk. Controlled, familiar and predictable batting drills. Increase heart rate activities to closer to maximum 
Add movement/
Non-contact training drills
Progression to more complex training drills, e.g. moderately challenging fielding drills. Batting against throws/machine (predictable). Bowling to empty net at 75-100%. May start progressive resistance training. Maximum cardiovascular stress 
Exercise, coordination and cognitive load 
Full-contact practice 
Following medical clearance, participate in normal/match preparation at high intensity, i.e. bowlers bowl to batsmen. Full batting, bowling and fielding 
Restore confidence and assess functional skills by coaching staff 
Return to play
Normal game play