Guidelines: When to Play, When to Quit
Dr. Robert Cantu, whose name is synonymous with "pioneer" in the concussion field, offers guidelines for return-to-play decision makers; when an athlete should terminate their season, and under what conditions it is safe to return to play after an injury. Chief of Neurosurgery at Emerson Hospital in Concord, Massachusetts, and co-director of the Center for the Study of Traumatic Encephalopathy, Dr. Cantu recently stated that children under the age of 14 should not play collision sports until changes are made to help keep their brains safe.
Cerebral concussion occurs frequently in contact sports; more than 250,000 concussion occur annually in football alone. Definitions and classifications of severity of concussion vary, which makes evaluation of data extremely difficult. By combining elements of various definitions, Dr. Cantu has developed a practical guide for determining safe return to play following concussion.
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No loss of consciousness OR signs/symptoms clear in 30 minutes |
May return to play after 1 week IF asymptomatic* at rest and during progressive exertion protocol |
May return to play in 2 weeks IF asymptomatic* for 1 week at rest and during progressive exertion protocol |
Terminate season; may return to play next season IF asymptomatic* at rest and during progressive exertion protocol |
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loss of consciousness for less than one minute OR more than 30 minutes posttraumatic amnesia OR signs/symptoms last less than 1 week |
May return to play IF asymptomatic* for 1 week and during progressive exertion protocol |
Out for a minimum of 1 month; may return to play IF asymptomatic* for one week at rest and during progressive exertion protocol consider terminating season |
Terminate season; may return to play next season IF asymptomatic* at rest and during progressive exertion protocol |
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loss of consciousness for one minute or longer OR more than 24 hours of posttraumatic amnesia OR signs/symptoms last more than 7 days |
Out for a minimum of 1 month; may return to play AFTER 4 weeks IF asymptomatic* for 1 week at rest and during progressive exertion protocol |
Terminate season; may return to play next season IF asymptomatic* at rest and during progressive exertion protocol |
*No headache, dizziness, or impaired orientation, concentration, or memory during rest or exertion
Note: A number of "modifying" factors may influence concussion management considerations beyond simple RTP advice. Some of these include number of, duration, and severity of symptoms, number of previous concussions, as well as history of migraines or depression. See Zurich guidelines Table 2.
Gradual return-to-play
The Zurich guidelines, as they are commonly called, were developed by a group of international experts who convened in Switzerland for the purpose of providing a document full of practical information on the subject of concussions. These guidelines include a gradual return-to-play protocol which is a step-wise process that allows the athlete to increase their heart rate and activity level after their physical symptoms have resolved, before returning to full activity. If symptoms reappear while following this protocol, it may be indicative of incomplete healing.
PHASE 1: no physical or cognitive activity
(complete rest) until asymptomatic.
PHASE 2: light aerobic exercise
walking, swimming, stationary cycling with intensity < 70% max. predicted heart rate. No resistance training.
PHASE 3: sport-specific training
skating drills in hockey, running drills in soccer. No head impact activity.
PHASE 4: non-contact drills
more complex training drills (passing drills in football or ice hockey). May start progressive resistance training.
PHASE 5: full-contact practice
following medical clearance, participate in normal training activities.
PHASE 6: return-to-play
normal game play
Note: If symptoms return during any part of the protocol, wait 24 hours and begin again at that same phase.
Source: Consensus statement on concussion in sport -- The 3rd International Conference on concussion in sport, held in Zurich, November 2008 Br J Sports Med 2009;43:i76-i84 doi:10.1136/bjsm.2009.058248
Questions/comments? Contact Jean Rickerson at This e-mail address is being protected from spambots. You need JavaScript enabled to view it.
