A concussion protocol is a standardized, step-by-step process for managing a concussion from the moment of injury through full return to sports or daily life. It covers immediate removal from play, symptom monitoring, cognitive and physical testing, rest, and a graduated return to activity. The core principle is simple: you advance through recovery stages one at a time, and if symptoms return at any point, you step back.
What Happens Right After the Injury
The first step in any concussion protocol is removing the person from play or activity immediately. There is no “playing through it.” Once removed, a healthcare provider or athletic trainer performs a sideline assessment to evaluate symptoms and determine next steps.
The most widely used sideline tool is the Sport Concussion Assessment Tool, now in its sixth version (SCAT6). It’s not a single test but a battery of checks that cover several areas:
- Orientation questions: What month is it? What’s today’s date? What day of the week? What time is it?
- Immediate memory: The person listens to a list of words and repeats back as many as they can, over three trials.
- Concentration: Repeating number strings in reverse order, or listing the months of the year backward as quickly as possible.
- Balance testing: Standing on one leg, standing heel-to-toe, and walking a straight line heel-to-toe, sometimes while counting backward by sevens.
- Coordination and eye movement: Finger-to-nose testing, and tracking objects side-to-side and up-and-down to check for double vision or abnormal eye movements.
A separate screening called the Vestibular/Ocular Motor Screening (VOMS) may also be used. It tests five specific areas: smooth eye tracking, rapid eye movements, the ability to focus on a close object, how well your eyes stabilize during head movement, and sensitivity to visual motion. If any of these trigger symptoms like dizziness, headache, or nausea, it flags the need for more specialized vision or balance rehabilitation later in recovery.
The First Days of Recovery
Current guidelines have moved away from the old advice of lying in a dark room for days. Brief rest in the first 24 to 48 hours is appropriate, but prolonged isolation can actually slow recovery. Screen time should be limited in the first one to two days, along with activities that are physically or mentally demanding. Light physical activity like going for walks is encouraged even if mild symptoms are still present.
Most children can return to school within one to two days of a concussion. The goal is to get back to normal routines as soon as reasonably possible, with adjustments as needed.
Returning to School
For students, the protocol includes a structured return-to-learn process that runs alongside (and typically ahead of) any return to sports. A school concussion management plan identifies a case manager as the primary point of contact and outlines who monitors the student’s symptoms throughout the day.
Classroom accommodations depend on the symptoms a student is experiencing. For thinking and memory problems, schools may reduce assignments to key tasks only, provide extra time on tests (limiting them to one per day), supply class notes, or allow a phone for recording classroom information. Grades are based on adjusted workloads.
For physical symptoms like headaches or light sensitivity, accommodations include rest breaks, extra time between classes to avoid crowded hallways, sunglasses indoors or seating away from windows, and a quiet space for studying, testing, or lunch. Students struggling with mood changes may benefit from having an identified adult they can talk to and a quiet space to go when feeling overwhelmed.
The 6-Step Return to Play Progression
The physical recovery side follows a six-step progression based on the International Concussion in Sport Guidelines. Each step takes a minimum of 24 hours, and an athlete can only move forward if no new symptoms appear at the current level. A healthcare provider must give approval before the process even begins.
- Step 1: Back to regular activities. The athlete is handling everyday tasks like school without symptoms and has been cleared by their healthcare provider to start the progression.
- Step 2: Light aerobic activity. Five to ten minutes on a stationary bike, walking, or light jogging. The only goal is gently raising the heart rate. No weightlifting.
- Step 3: Moderate activity. Moderate jogging, brief running, moderate-intensity biking, and lighter-than-usual weightlifting. Activities now include body and head movement.
- Step 4: Heavy non-contact activity. Sprinting, high-intensity biking, a full weightlifting routine, and sport-specific drills that don’t involve contact.
- Step 5: Full-contact practice. The athlete returns to practice with full contact in a controlled setting.
- Step 6: Competition. Full, unrestricted return to game play.
At minimum, the progression takes six days if everything goes smoothly. In practice, it often takes longer.
What Happens When Symptoms Return
The step-back rule is the most important safety mechanism in the protocol. If symptoms come back or new ones appear at any stage, the athlete stops activity immediately. This is a sign the brain is being pushed too hard. After resting until symptom-free again, the athlete drops back to the previous step and restarts from there.
There is no skipping steps and no pushing through symptoms. Parents, coaches, and athletic trainers all play a role in watching for signs after each day’s activity. Common symptoms to watch for include headache, dizziness, difficulty concentrating, nausea, sensitivity to light or noise, and feeling “foggy” or slowed down.
Who Can Clear You to Play
A healthcare provider must authorize the athlete’s entry into the return-to-play progression and supervise the process throughout. Coaches and parents cannot make clearance decisions on their own, no matter how well the athlete appears to feel. When available, a certified athletic trainer works closely with the family and medical provider to monitor progress at each step.
Every U.S. state now has some form of concussion law governing youth sports, and most require written clearance from a licensed healthcare professional before an athlete can return to competition. The specifics vary by state, but the underlying standard is the same: no one goes back to contact play without medical sign-off.