14.3 Concussion Return-to-Learn & Return-to-Sport

Quick Answer: NATA 2024 Bridge Statement (Broglio, Register-Mihalik, Guskiewicz, Leddy, Merriman, Valovich McLeod, JAT 59(3):225–242) plus Amsterdam / Concussion in Sport Group (CISG) 2022: relative rest about 24–48 hours, then symptom-limited activity. Return-to-learn (RTL) before or in parallel with return-to-sport (RTS) — not after full sport clearance. Six RTS steps: (1) symptom-limited activity, (2) aerobic (2A light ~55% max HR, then 2B moderate ~70%), (3) individual sport-specific, then after symptom, cognitive, and clinical resolution including with exertion: (4) non-contact training, (5) full-contact practice, (6) return to sport. Each step typically ≥24 hours. No same-day return. Do not cocoon in a dark room for a week.

This section is concussion return, not sideline diagnosis (Chapter 11 covered catastrophic head/spine). The documents the exam and the athletic training room now share are the 2024 NATA Bridge Statement (an update bridging the 2014 NATA concussion position statement to current evidence) and the 6th International Conference on Concussion in Sport — Amsterdam, October 2022 (Patricios, Schneider, Dvorak, et al., BJSM 2023;57:695–711). NATA reprints the CISG RTS table as Table 12 and the return-to-academics strategy as Table 10.

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What the 2024 Bridge actually changed

The Bridge adds more than 25 new or updated recommendations. The items that change daily practice:

• Unchallengeable medical authority of licensed medical professionals (ATs and physicians) for concussion decision-making, in collaboration with administrators (Table 1 update). Coaches do not clear concussions.
• Relative rest 24–48 hours, not strict rest. During the acute stage, avoid physical or mental exertion that exacerbates symptoms more than mildly (update to 2014 recommendation 39). Mild = an increase of ≤2 points on a 0–10 scale versus the pre-activity value, lasting <1 hour.
• Controlled, subsymptom-threshold aerobic exercise can begin as soon as 1–2 days after injury if resting symptoms are stable (not getting worse) and not severe, regardless of motor-control and neurocognitive scores (update to 2014 rec 22; SOR A).
• Aerobic exercise that does not exacerbate more than mildly is treatment or medicine for concussion (SOR A), including early prescription after determining exercise tolerance and later use for persisting symptoms.
• Targeted multidimensional active rehabilitation (vestibular, cervicovestibular, exertional) when directed by a trained clinician (SOR A).
• RTL: after a short period of cognitive rest (24–48 hours), student-athletes can begin physically returning to school, with academic supports as needed; use a gradual, stepwise strategy and an interdisciplinary school-based concussion management team.
• No same-day return to athletic participation on the day of injury remains in force (2014 recommendation 19 was not revised — still do not send them back in that contest).
• Mental health screening and a biopsychosocial model are new Bridge content: preexisting anxiety or depression raises the risk of prolonged recovery; screen, refer, and watch how academic failure feeds mood.

Cocooning — dark room, no walking, no social contact, total screen bans for a week — is explicitly the negative of strict rest. It is now level 1 evidence that clinically directed activity that does not more than mildly exacerbate symptoms facilitates recovery and reduces delayed recovery in adolescents (Leddy and colleagues' subsymptom aerobic work is the literature the Bridge leans on).

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Return-to-learn: before or beside sport, never after the championship

NATA Table 10 (CISG return-to-academics strategy). After relative rest 24–48 hours at step 1, increase cognitive load. Slow the progression if there is more than a mild and brief symptom exacerbation.

1. Daily activities that do not result in more than mild/brief exacerbation — typical daytime activity (for example, reading) while minimizing screen time. Start with 5–15 minutes at a time and increase gradually. Goal: gradual return to typical activities.
2. School activities outside the classroom — homework, reading, other cognitive work at home. Goal: increase tolerance to cognitive work.
3. Return to school part time — partial day and/or more rest breaks. Goal: increase academic activities.
4. Return to school full time — a full day tolerated without more than mild exacerbation; then catch up on missed work.

Not every student needs a 504 plan or IEP. Many need only temporary adjustments: sunglasses, sitting away from bright light, extra time, shorter assignments, a lighter load, hall passes for headache or dizziness. Formal accommodations exist for persisting problems; the AT contributes symptom and testing information but does not personally 'prescribe' a 504. CISG recommended that children and adolescents not be cleared for full return to competition until they have successfully completed return to school. Early RTS steps 1–3 (symptom-limited activity, aerobic exercise, individual sport-specific work without head-impact risk) can run in parallel with RTL. Contact sport does not precede sitting through class.

Exam trap: 'return to football before he can sit through class.' Academic recovery is not a reward you save until after the playoff game.

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Amsterdam / CISG 2022 RTS: six steps (older five-step talk is outdated)

Berlin 2016 used a familiar graduated RTS. Amsterdam kept six numbered steps but split aerobic exercise into 2A and 2B, named step 3 as individual sport-specific exercise (away from the team, no head-impact risk), and drew a hard line: steps 4–6 start only after symptoms, cognitive abnormalities, and other clinical findings related to this concussion have resolved, including with and after physical exertion. Steps 1–3 are the treatment / therapeutic phase. Each step typically takes a minimum of 24 hours (NATA Table 12 footnote). Athletes may begin step 1 within 24 hours of injury.

Step 1 — Symptom-limited activity. Daily activities that do not exacerbate symptoms (for example, walking). Goal: gradual reintroduction of work or school.

Step 2 — Aerobic exercise. 2A light (up to about 55% of age-predicted max HR, often taught as 220 − age), then 2B moderate (up to about 70% max HR). Stationary cycling or walking at a slow-to-medium pace. May start light resistance training that does not cause more than mild/brief exacerbation. Goal: increase heart rate. This is also where a clinician with a treadmill or bike protocol (Buffalo Concussion Treadmill Test and related subsymptom-threshold prescription) can dose aerobic treatment.

Step 3 — Individual sport-specific exercise. Sport-specific training away from the team environment (running, change of direction, individual drills) with no activities that risk head impact. If sport-specific training involves any risk of inadvertent head impact, medical clearance should occur before step 3. Goal: add movement and change of direction.

Then the gate: steps 4–6 begin after resolution of symptoms, cognitive abnormalities, and other clinical findings, including with and after physical exertion. Written determination of readiness from a health-care provider is required before unrestricted clearance as directed by state law and sport regulations.

Step 4 — Non-contact training drills. High-intensity exercise, more challenging drills (passing, multiplayer), can integrate into a team environment — still non-contact. Goal: usual intensity, coordination, and increased thinking.

Step 5 — Full-contact practice. Normal training activities. Goal: restore confidence and assess functional skills with coaching staff.

Step 6 — Return to sport. Normal game play.

How to fail a step. During steps 1–3, more than mild exacerbation (>2 points on 0–10) means stop that session; the athlete typically retries after symptoms settle (often the next day at the same or prior step). During steps 4–6, concussion-related symptoms mean return to step 3 to re-establish full symptom resolution with exertion before at-risk activity. Do not 'push through' a worsening headache to keep a starter on the field.

No same-day return. A hockey or football player who is briefly unsteady then says he is fine at the next whistle does not go back in that contest. Lystedt-style laws in all 50 U.S. states require removal and written clearance from an appropriate provider. The Bridge did not loosen that rule.

Unrestricted RTS after sport-related concussion often occurs within about a month, but that is a description of many recoveries, not a promise and not a deadline. Persisting symptoms (adults often flagged around >2 weeks, children/adolescents around >4 weeks in concussion literature) need a multimodal evaluation, not a darker room.

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Vestibular, cervical, exertional rehab — and the mind

Amsterdam: cervicovestibular rehabilitation is indicated for athletes with neck pain, headaches, dizziness, and/or balance problems. Vestibular/Ocular Motor Screening (VOMS) domains — smooth pursuit, saccades, near-point convergence, vestibular-ocular reflex, visual motion sensitivity — help target those referrals. A normal computerized cognitive test does not rule out a vestibular or cervical driver. Exertional intolerance may reflect impaired autonomic regulation; subsymptom aerobic work is the treatment, not prolonged bed rest.

Psychological aspects are not optional color. Isolation from teammates, identity loss, fear of falling behind academically, coach or parent pressure, and preexisting anxiety or depression all change recovery. The Bridge tells ATs to screen, to refer, and to have the school-based team watch adverse academic effects on mental health. Driving is a separate safety talk: reaction time can remain slowed even after symptoms resolve; alternative transport is reasonable until the physician and AT are comfortable.

Exam traps: (1) 'Cocoon in a dark room for a week' — outdated, can worsen symptoms and mood. (2) 'Return to football before he can sit through class' — RTL first or in parallel; full-contact RTS last. (3) Same-day return because the SAC 'looked close enough.'