Hey Doc, When Can I Return to Play?

A Heads-Up on Managing Concussion in Sports

David E. Sugerman, MD, MPH


November 28, 2011

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Hi, I am Dr. David Sugerman, an emergency department physician with the Centers for Disease Control and Prevention. I am here to speak with you as part of the CDC Expert Commentary Series about helping young athletes safely return to play after a concussion.

For many of us, the first chance to assess a young athlete with a suspected concussion will not be on the sidelines, but in our office or emergency department. Your examination will likely include a physical examination, covering cognition, neurology, balance, and, most important, any signs of deteriorating neurologic function.

When managing an athlete with concussion, your management plan should cover both returning to school and to play and should:

  • Monitor both physical and cognitive activities;

  • Consider concussion history; and

  • Be individualized to the athlete.

Outside of the emergency department, in most cases, it will be possible to monitor the athlete where you work, especially if the number and severity of symptoms are steadily decreasing and gone within 7-14 days.

An athlete seen initially in an emergency department should be referred for follow-up care to a healthcare professional who can help him or her gradually return to school and to play when fully recovered. An athlete should not leave an emergency department and return to practice or play the same day, nor should a future return to practice or play date be given at the time of an emergency department visit.

There are 5 gradual steps to help safely return an athlete to play, adapted from the International Concussion Consensus Guidelines.

As the baseline step of the "Return to Play Progression," the athlete needs to have completed physical and cognitive rest and should not be experiencing concussion symptoms for a minimum of 24 hours. Keep in mind that the younger the athlete, the more conservative the treatment. These are the 5 steps of the "Return to Play Progression":

Step 1: Light aerobic exercise. The goal is only to increase the athlete's heart rate. Exercise time is 5-10 minutes and includes exercise bike, walking, or light jogging -- absolutely no weightlifting, jumping, or hard running.

Step 2: Moderate exercise. The goal is to limit body and head movement. Exercise time is reduced from a typical routine. Activities include moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting,

Step 3. Noncontact exercise. The goal is more intensity but without contact. Time should be close to the athlete's typical exercise routine, and activities can include running; high-intensity stationary biking; the player's regular weightlifting routine; and noncontact, sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in steps 1 and 2.

Step 4. Resume practice. The goal of this step is to reintegrate in full-contact practice.

Step 5. Return to play. The goal of this final step is to return to competition.

It is important to monitor symptoms and cognitive function carefully during each increase of exertion. Athletes should only progress to the next level of exertion if they are not experiencing symptoms at the current level. If symptoms return at any step, the athlete should be instructed to stop the activity, because this may be a sign that the athlete is pushing too hard. Only after additional rest, when the athlete is no longer experiencing symptoms, for a minimum of 24 hours, should the athlete begin again at the step during which symptoms were experienced.

The "Return to Play Progression" process is best conducted through a team approach and by a health professional who knows the athlete's physical abilities and endurance level. By gauging the athlete's performance on each individual step, you will be able to determine how far the athlete can progress on a given day. In some cases, you may be able to work through 1 step in a single day, whereas in other cases, it may take several days to work through an individual step. It may take several weeks to months to work through the entire 5-step progression.

Before the start of the season, learn about your state, league, or sports governing body's laws or policies on concussion. Some policies may require the athlete to take a training program or provide written clearance as part of the return to play process.

Remember: While most athletes will recover quickly and fully following a concussion, some will have symptoms for weeks or longer. You should consider referral to a concussion specialist if:

  • The symptoms worsen at any time;

  • Symptoms have not gone away after 10-14 days; or

  • The patient has a history of multiple concussions or risk factors for prolonged recovery. These may include a history of migraines, depression, mood disorders, or anxiety, as well as developmental disorders such as learning disabilities and ADHD.

More details on diagnosing and managing concussion among young athletes, including returning to school planning, are included in CDC's online course for healthcare professionals, Heads Up to Clinicians.

David E. Sugerman graduated from Thomas Jefferson Medical College in 2004, completed a Masters of Public Health at the Johns Hopkins School of Public Health in 2003, and his residency in emergency medicine at the Johns Hopkins Hospital in 2007. He subsequently joined the CDC Epidemic Intelligence Service as a medical officer in San Diego County (2007-2009), working on communicable disease control, followed by a position at the Global Immunization Division, Africa Team (2009-2010).

Dr. Sugerman's public health research activities have focused on vaccine-preventable diseases, syndromic surveillance, health system strengthening, outbreak response, and injury prevention. Past projects have included a WHO-funded, Global Childhood Unintentional Injury Surveillance System (GCUIS) in Colombia, Egypt, Bangladesh, Pakistan, and Uganda, along with injury surveillance among long-term Afghan refugees living in Pakistan; measles outbreak response among children with personal belief exemptions; H1N1 pandemic response; meningitis and multi-drug-resistant tuberculosis (MDR-TB) surveillance along the US-Mexico border; monkeypox surveillance with the US Army in Kole, Democratic Republic of Congo; polio and measles control in West Africa; and technical assistance to UNICEF and the Haitian Ministry of Health on vaccination campaigns after the 2011 earthquake. Current work in the Division of Injury Response has focused on traumatic brain injury and prehospital triage of injured patients. In addition, Dr. Sugerman works clinically at the Emory University Hospital Emergency Department.


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