A concussion protocol is a structured set of steps that guides someone from the moment of a head injury through full recovery. It covers immediate assessment, a brief rest period, and then a gradual return to physical activity, school, and eventually sports. The process isn’t one-size-fits-all, but the core framework is used across youth leagues, professional sports, schools, and military settings.
What Happens Immediately After a Hit
The first priority is recognizing that a concussion may have occurred and pulling the person from activity. Sideline tools like the Concussion Recognition Tool (CRT6) and the Sport Concussion Assessment Tool (SCAT6) are designed to be used within the first 72 hours. The SCAT6 tests several domains: orientation questions (what month is it, what day of the week), immediate and delayed word recall, concentration tasks like reciting months in reverse order, and a balance examination that includes standing on one leg, walking heel-to-toe, and walking heel-to-toe while counting backward by sevens.
A separate screening called the Vestibular/Ocular-Motor Screening (VOMS) checks how well the eyes and balance system are working together. It involves tracking a moving finger, shifting the eyes quickly between two points, and turning the head while focusing on a fixed target. After each task, the person rates their headache, dizziness, nausea, and fogginess on a 0 to 10 scale. One specific test measures how close the eyes can focus on an object moving toward the nose. A convergence point of 5 centimeters or more from the nose is considered abnormal.
None of these tools replace a medical evaluation. They help determine whether someone needs to stop playing and see a healthcare provider.
Danger Signs That Need Emergency Care
Most concussions are managed by a primary care provider, but certain symptoms signal something more serious, like bleeding in the brain. Go to an emergency department if you see any of the following after a head injury:
- Seizures or convulsions
- Inability to recognize people or places
- Repeated vomiting
- Increasing confusion, restlessness, or agitation
- Loss of consciousness, increasing drowsiness, or inability to stay awake
- Slurred speech, weakness, numbness, or loss of coordination
- A headache that keeps getting worse
- One pupil larger than the other, or double vision
For infants and toddlers, inconsolable crying or refusal to nurse or eat are additional warning signs on top of the list above.
The First 24 to 48 Hours
The old advice was to rest in a dark room for days. That’s no longer recommended. Current guidelines call for roughly 24 to 48 hours of relative rest, meaning you can do normal daily activities like walking as long as they don’t make symptoms worse. Prolonged strict rest can actually slow recovery by increasing anxiety, depression, and isolation.
After that initial window, light aerobic activity is encouraged. This is a significant shift in concussion management. Strong evidence now supports early physical activity and aerobic exercise as beneficial interventions. Working at a level that stays below the point where symptoms flare up (typically 60% to 80% of the heart rate at which symptoms appear) has been shown to improve cognitive function, sleep, mood, and overall well-being.
The 6-Step Return to Sports
Returning to sports follows a graduated progression laid out by the CDC. Each step takes a minimum of 24 hours. If symptoms return at any stage, you drop back to the previous step and try again after resting.
- Step 1: Back to regular daily activities like school, with clearance from a healthcare provider to begin the progression.
- Step 2: Light aerobic activity only, such as 5 to 10 minutes on a stationary bike, walking, or light jogging. No weight lifting.
- Step 3: Moderate activity that increases heart rate with body or head movement. Moderate jogging, brief running, moderate-intensity biking, and reduced weightlifting.
- Step 4: Heavy non-contact activity. Sprinting, high-intensity biking, full weightlifting routine, and sport-specific drills in multiple directions.
- Step 5: Full practice, including contact if appropriate for the sport.
- Step 6: Return to competition.
The entire process takes at least a week and often longer. One critical rule: the athlete should be fully back to all regular non-sport activities, without any accommodations or support, before finishing the return-to-sports protocol.
Returning to School
For students, getting back to the classroom is typically the first milestone. Most children can return to school within one to two days of a concussion, and research has found that delaying return may actually lead to a longer recovery. The key is making temporary adjustments to the workload based on the student’s specific symptoms.
If thinking and memory are affected, schools can reduce assignments to key tasks only, provide extra time on tests (limiting to one test per day), supply class notes, or allow a phone to record lectures. Grades should be based on adjusted work during this period.
For physical symptoms like headaches and light or noise sensitivity, accommodations include rest breaks, extra time between classes to avoid crowded hallways, sunglasses or seating away from windows, and a quiet place for studying or lunch. If the student is experiencing mood changes, having a designated adult they can talk to when feeling overwhelmed and maintaining social connections with friends both support recovery.
These supports are removed gradually as symptoms improve.
Recovery Timeline
Most children with a concussion feel better within two to four weeks. Adults generally follow a similar timeline, though recovery can vary widely depending on the severity of the injury, previous concussion history, and individual factors. For people whose symptoms persist beyond four weeks, the latest international consensus recommends a multimodal clinical assessment using standardized symptom rating scales and newer office-based tools (the SCOAT6) designed specifically for serial evaluations in the weeks following injury.
Symptoms that linger often involve dizziness, balance problems, neck pain, or headaches. For these, cervicovestibular rehabilitation, a form of physical therapy targeting the neck and balance system, is specifically recommended. An active rehabilitation approach that includes supervised aerobic exercise has been shown to reduce depression and help restore normal function more effectively than continued rest.
How Children’s Protocols Differ
The core framework is the same for children and adults, but younger children present unique challenges. Infants, toddlers, and preschoolers can’t always describe their symptoms, so caregivers need to watch for behavioral changes: more crying than usual, seeking extra comfort, changes in sleep patterns, loss of interest in play, appearing dazed or clumsier than normal, or speaking more slowly. Healthcare providers may need to adapt the standard recovery guidance for young children and children with disabilities who can’t reliably communicate how they feel.
The return-to-school and return-to-sports progressions can happen simultaneously for children, but the academic return should always be prioritized. A student shouldn’t be finishing the sports protocol while still needing classroom accommodations.
Prevention Strategies
The latest international consensus statement identifies three evidence-based prevention approaches: rule and policy changes that reduce the frequency and intensity of collisions, neuromuscular training programs incorporated into warm-ups (exercises that improve neck strength, balance, and body control), and mouthguard use in ice hockey. These strategies don’t eliminate concussion risk, but they meaningfully reduce it at a population level.