Concussion Return-to-Play: The Six-Step Protocol and What Each Step Means

Quick answer. The current standard-of-care concussion return-to-play framework is the six-step graduated return to sport described in the Consensus Statement on Concussion in Sport. Steps run in order, with at least 24 hours at each step, a medical clearance before full contact, and a symptom-based pause-and-step-back rule that overrides the calendar. The sport physiotherapist's job is to drive the testing, the graded reintroduction of load, and the communication between athlete, family physician, and team. The decision-maker on return to contact is the physician, not the physio.

If your North Shore athlete — a high school hockey player, a rugby flanker at Capilano, a soccer midfielder in the Lower Mainland Soccer League, a club rower — has had a concussion in the last week, the next two to four weeks should look more structured than "rest until it feels okay".

The six steps of return to sport

The framework most commonly used in Canada is the six-step Graduated Return to Sport progression from the Consensus Statement on Concussion in Sport — 6th International Conference (Amsterdam, 2022), published in BJSM. Each step is described as taking a minimum of 24 hours, with progression contingent on symptom stability.

Step 1 — Symptom-limited activity. The first 24 to 48 hours after the concussion. Daily activities are tolerated within symptom limits. Brief, low-intensity walking is encouraged. Screen exposure is moderated based on symptom response. Prolonged dark-room rest is no longer the standard.

Step 2 — Light aerobic exercise. Walking and stationary cycling at low intensity, sub-symptom threshold. Heart rate typically below 70% of maximum. Goal is to introduce cardiovascular activity without provoking symptoms. No resistance training, no head impact.

Step 3 — Sport-specific exercise. Running drills or skating drills in the case of hockey. No head impact, no contact. Movement patterns are sport-specific but the cognitive and collision load is low.

Step 4 — Non-contact training drills. Progression to harder training drills — passing patterns, set plays, more complex movement. Resistance training can be reintroduced. The athlete is in a team practice context but the contact element is held back. This step often takes longer than 24 hours in adolescent athletes.

Step 5 — Full-contact practice. Following medical clearance, the athlete returns to normal training activities. This is the first step where the head can take impact. Coaches monitor for changes in performance, behaviour, or symptoms.

Step 6 — Return to sport. Normal game play.

The 24-hour minimum at each step means a fully smooth progression is at least a week. Real recoveries rarely move that fast, particularly in adolescents and in athletes with prior concussion history.

The symptom-based step-back rule

The protocol's most important detail is not the steps themselves but the rule that governs them: if symptoms return when load is added at any step, the athlete drops back to the previous step and waits until symptoms settle before re-attempting the progression.

This is where the framework most often gets eroded in practice. A symptom flare on step 3 is not a signal to push through. It is a signal that the tissue or the brain's processing capacity is not ready for that level of load yet. The right move is the same as in any other rehab — back off, settle, retry. Pushing through with symptoms can prolong recovery and, in the case of a second impact during a symptomatic window, carries a small but real risk of more serious injury.

We tell every athlete the same thing on day one: the protocol is not a race. The athlete who progresses smoothly through is back faster than the athlete who pushes step 4 too soon and bounces back to step 2.

Return-to-learn runs in parallel

For students and student-athletes, the cognitive recovery side runs in parallel. The same Amsterdam consensus describes a Graduated Return to Learn protocol — daily activities at home, then school work at home in short blocks, then partial school day with academic accommodations, then full school day with accommodations, then full participation.

The principle that connects the two protocols: cognitive load is reintroduced before high-intensity physical load. A North Shore high school student returning to a full day of class with screen-heavy coursework while also pushing toward step 4 of return-to-sport is overloading both systems. We coordinate the rate of school progression with the rate of sport progression. School-based concussion accommodations are commonly arranged through the school's counsellor or learning support teacher.

What testing the physiotherapist actually contributes

The physiotherapist's contribution is in three areas:

• Cervical assessment. A significant portion of post-concussion symptoms — headache, dizziness, sense of disorientation — overlap with cervical spine dysfunction from the same impact. We screen the upper cervical joints, the cervical proprioception, and the suboccipital tone. The cervical contribution is sometimes the missing piece in a recovery that has stalled.
• Vestibular-ocular and balance testing. A standardised VOMS-style screen identifies vestibular and ocular motor symptoms that benefit from targeted exercise. Athletes who fail the smooth pursuit, saccade, or convergence components often progress faster with vestibular rehab than with continued rest.
• Sub-symptom-threshold exertion testing. A graded treadmill or stationary bike test, modelled on the Buffalo Concussion Treadmill Test, identifies the heart rate at which symptoms increase. That heart rate becomes the ceiling for sub-symptom-threshold aerobic activity in steps 2 and 3.

Sport Concussion Assessment Tool (SCAT6) symptom tracking is the spine of the clinical record. We score it at intake and at progression steps so the family physician and the athlete have an objective record of change.

Where the physician fits

The medical clearance before step 5 (full-contact practice) is not optional. A family physician with concussion experience, a sport medicine physician at a centre like the University of British Columbia Sport Medicine Clinic, or a designated medical officer for a regulated sport is the appropriate decision-maker. The clearance reflects the full picture — symptom resolution, exertion testing, prior history, and the athlete's specific sport context.

For minor amateur sport in BC, organisations such as Hockey Canada and Rugby Canada have published their own concussion protocols that align with the Amsterdam consensus. The Parachute Canada Canadian Guideline on Concussion in Sport is the national reference document used by many BC sport bodies.

What changes for kids

Adolescent athletes recover more slowly than adults on average. The literature recommends a minimum of 14 days symptom-free at rest and seven days symptom-free with exertion before return to contact in youth sport, which functionally lengthens the protocol. The clinical reasons — ongoing brain maturation, less developed reporting of subtle symptoms, school-day cognitive load — all push toward a more conservative timeline.

The honest version we share with families at Medstar: a clean adolescent concussion in our clinic averages closer to three to four weeks before full contact, not seven days. The patient who reports symptom resolution on day three is rarely the patient who is back to full contact on day seven.

This article is general information about concussion return-to-play. It is not personal medical advice. Concussion management requires a physician's involvement, and clearance for full contact must come from a physician.

Sources

• Consensus Statement on Concussion in Sport — 6th International Conference (Amsterdam, 2022), BJSM
• Parachute Canada — Canadian Guideline on Concussion in Sport
• UBC Sport Medicine Clinic / British Columbia College of Sport Medicine
• College of Physical Therapists of BC (CPTBC)