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Kids' Concussion Return-to-Play: What the Updated 2025 Protocols Actually Require
Rest is no longer the default for kids' concussions. Here's what the updated 2023 Amsterdam Consensus and AAN protocols actually require for return-to-play and return-to-learn.
When a 12-year-old took a hit at a soccer match and was diagnosed with a concussion, her parents did what they’d been told to do — they pulled her from all activities, kept the lights low, banned screens, and waited for her symptoms to resolve. Two weeks later she was more symptomatic than before, increasingly anxious, and falling behind in school. The problem wasn’t their intentions. The problem was that the advice they followed was based on concussion management research from the early 2000s, and the field has changed significantly since. The 2023 Amsterdam Consensus Statement on Concussion in Sport — the most comprehensive international review of concussion evidence — formally shifted the standard of care away from strict rest and toward structured, active rehabilitation beginning within 24–48 hours of injury.
Key Takeaways
- Current evidence-based concussion management recommends 24–48 hours of rest followed by graduated active rehabilitation — not prolonged rest until symptom-free.
- “Symptom-free” is no longer the only criterion for return-to-play; functional capacity and passage of protocol stages also matter.
- The return-to-play protocol is a minimum 6-stage graduated process with specific criteria for each stage transition.
- A parallel return-to-learn protocol should run alongside — not after — the return-to-play protocol.
- ImPACT and similar computerized testing have significant limitations as the sole determinant of clearance; clinical judgment by a qualified provider remains essential.
Why the Management Has Changed
The prior standard — strict rest until completely symptom-free — was based on the premise that any neurological activity during recovery could worsen outcomes. Research has largely not supported this. In fact, multiple studies now show that prolonged strict rest is associated with:
- Prolonged symptom duration (rest doesn’t speed recovery; it may slow it)
- Deconditioning that makes exercise intolerance worse
- Increased psychological distress, particularly anxiety and depression
- Greater school reintegration difficulties when return is delayed
A 2021 study in JAMA Pediatrics randomized pediatric concussion patients to either 5 days of strict rest or 1–2 days of rest followed by progressive sub-threshold aerobic exercise. The active rehabilitation group recovered faster and had better symptom trajectories at 14 days. This aligned with growing evidence that aerobic exercise, carefully introduced below the symptom-exacerbating threshold, actually promotes recovery rather than impeding it.
The 2023 Amsterdam Consensus Statement formalized this shift. It explicitly states that the evidence no longer supports prolonged rest as standard treatment and endorses structured active rehabilitation beginning within 24–48 hours in most cases.
What “Symptom-Free” Actually Means Clinically
This is a phrase that causes significant confusion. Parents often interpret it as “when the child says they feel fine.” Clinically, it means considerably more.
The symptom inventory used in formal concussion assessment typically includes 22+ symptoms across physical (headache, nausea, visual disturbance), cognitive (mental fogginess, concentration difficulty, slowed processing), and sleep/emotional domains. Clinical “symptom-free” means scoring zero on all domains of a validated tool like the Sport Concussion Assessment Tool (SCAT6) — not just the absence of headache.
Moreover, under current protocols, symptom resolution alone is not sufficient for return-to-sport clearance. The athlete must also complete each stage of the graduated return-to-play protocol successfully. A child can be symptom-free and still fail Stage 3 of the protocol if exertion triggers symptoms — which would mean they are not ready to progress.
The 6-Stage Return-to-Play Protocol
The graduated return-to-sport (GRTS) protocol from the 2023 Amsterdam Consensus has six stages. Each stage requires a minimum of 24 hours, meaning the fastest possible protocol completion is 6 days — and most athletes take longer.
| Stage | Activity | Objective | Transition Criteria |
|---|---|---|---|
| 1 | Rest (24–48 hours) | Recovery | No symptom worsening; ready for Stage 2 |
| 2 | Light aerobic exercise (walking, swimming, stationary bike) | Increase heart rate | No symptoms during activity |
| 3 | Sport-specific exercise (skating drills, running) | Add movement patterns | No symptoms during activity |
| 4 | Non-contact training drills | Cognitive load + coordination | No symptoms; coach/trainer cleared |
| 5 | Full-contact practice | Restore confidence; assess under normal conditions | Medical clearance; no symptoms |
| 6 | Return to competition | Full return | Completion of Stage 5 without symptoms |
Critical rule: If any stage triggers symptoms, the athlete drops back to the previous symptom-free stage and tries again after 24 hours. Trying to push through symptoms is not permitted under the protocol.
Who can clear for Stage 5? Full-contact practice and Stage 5 require clearance from a licensed healthcare provider trained in concussion management — ideally a physician, nurse practitioner, athletic trainer, or neuropsychologist with specific concussion training. This is not a coach call or parent call.
The Return-to-Learn Protocol
The return-to-learn (RTL) protocol is separate from but parallel to the return-to-play protocol. Many school systems lag behind in implementing it, and parents need to advocate for it explicitly.
Under the 2023 consensus recommendations, the return-to-learn sequence proceeds as follows:
| Stage | Activity Level | School Accommodation |
|---|---|---|
| 1 | Rest at home | No school |
| 2 | Limited cognitive activity (15–20 min) | Partial school day; no testing |
| 3 | Regular cognitive activity without accommodations if symptom-free | Return to school; accommodations in place |
| 4 | Full cognitive load with accommodations as needed | Full school day; reduced homework, extended time |
| 5 | Full return without accommodations | Full academic return |
A 504 plan can cover the school accommodation sequence. Typical accommodations during concussion recovery include: reduced homework volume, extended time on tests, no standardized or high-stakes testing during active recovery, access to a quiet/dimly lit space, and flexibility on attendance.
The essential point: return-to-learn should begin as soon as tolerable — typically before physical return to sports — not after. The research does not support holding a child out of all school until they are fully recovered. Cognitive activity at sub-threshold levels does not impair recovery when managed appropriately.
Return-to-Play vs. Return-to-Learn Protocol Stages Compared
| Step | Return-to-Play | Return-to-Learn | Minimum Time Each |
|---|---|---|---|
| Stage 1 | Complete rest (24–48 hrs) | Rest at home | 1 day |
| Stage 2 | Light aerobic activity | Limited school activity | 1 day |
| Stage 3 | Sport-specific exercise | Regular activity, accommodations | 1 day |
| Stage 4 | Non-contact drills | Full day with accommodations | 1 day |
| Stage 5 | Full-contact practice | Full return without accommodations | Medical clearance required |
| Stage 6 | Return to competition | N/A | N/A |
ImPACT Testing: What It Can and Can’t Tell You
ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) is a computerized neurocognitive battery commonly used in sports concussion management. Schools and sports programs use it as a baseline measure, and post-concussion ImPACT scores are often compared to that baseline.
ImPACT can provide useful information — particularly for detecting cognitive performance deficits that might not be apparent on clinical exam. But its limitations are real and well-documented:
- Test-retest reliability is moderate, not high — scores can vary between sessions due to effort, fatigue, anxiety, and practice effects
- A return to baseline ImPACT score does not equal full recovery; structural and functional changes can persist after cognitive test scores normalize
- Many athletes — particularly older adolescents — are sophisticated enough to game baseline tests (performing deliberately poorly so that post-concussion scores look “recovered”)
- In a 2021 review in British Journal of Sports Medicine, researchers found that ImPACT had limited sensitivity for detecting concussion when used alone
The clinical consensus is that ImPACT is a useful adjunct, not a standalone clearance tool. Return-to-play decisions should be made by a qualified clinician based on clinical exam, symptom inventory, functional assessment, and ImPACT results together — not ImPACT results alone.
When to See a Specialist vs. Primary Care
Most concussions can be managed appropriately by a primary care physician or pediatrician with current concussion training. Specialist referral is appropriate when:
- Symptoms are not improving by 4 weeks (post-concussion syndrome)
- Vestibular symptoms (dizziness, balance problems) are prominent and persistent
- Vision symptoms (blurring, tracking problems) are significant
- Significant mood disruption (depression, anxiety) has developed
- The athlete has a history of multiple prior concussions
- The clinical picture is unusual or complex
Specialists relevant to concussion management include: sports medicine physicians, pediatric neurologists, neuropsychologists, vestibular physical therapists (for dizziness/balance rehabilitation), and vision therapists (for visual tracking issues).
What to Watch For Over 3 Months
Weeks 1–4: Most children will see significant symptom improvement within this window. Track symptoms formally — use the Post-Concussion Symptom Scale or a similar tool — because informal tracking misses subtle changes. School performance is a sensitive early indicator. A child who is attending school but suddenly performing significantly below their baseline may have unmanaged cognitive symptoms.
Weeks 4–8: If symptoms are not substantially improving by week 4, this meets criteria for persistent post-concussive symptoms and warrants a specialist evaluation. Do not continue waiting. The clinical trajectory at 4 weeks is a meaningful predictor, and earlier specialist involvement improves outcomes.
Month 3: A child who has fully completed the graduated protocols and returned to both school and sport without symptom recurrence has done well. If any stage of the return-to-play protocol is still stalling at 3 months, this is beyond routine concussion management territory and requires a comprehensive multidisciplinary evaluation.
Red flags at any point: Severe headache worsening rapidly, loss of consciousness, repeated vomiting, one pupil larger than the other, seizure, increasing confusion, or weakness in one arm or leg — these indicate a potential serious intracranial injury and require immediate emergency evaluation.
Frequently Asked Questions
How long does a concussion typically take to heal in a child?
Most children with a first concussion recover within 4 weeks when managed with current evidence-based protocols. However, recovery duration varies significantly — younger children, those with a prior concussion history, and those with pre-existing anxiety or learning differences may take longer. The critical point is that prolonged strict rest does not speed recovery and may slow it.
My coach says my kid is fine and wants to put them back in. What should I do?
A coach cannot clear an athlete for return-to-play. Under current protocols, Stage 5 (full-contact practice) and Stage 6 (competition) require clearance from a licensed healthcare professional with concussion training. If a coach is pressuring return before medical clearance, decline and bring a written note from the treating provider explaining the protocol requirements.
Can my child play a different sport while recovering from a concussion in their primary sport?
No. The return-to-play protocol applies to all contact and collision sports, not just the one where the concussion occurred. A child recovering from a soccer concussion cannot participate in basketball while completing the protocol. The distinction between sports does not change the brain’s recovery status.
What’s the difference between a concussion and a more serious brain injury?
Concussion is a functional, not structural, brain injury — imaging (CT, MRI) is typically normal. A more serious injury (contusion, hemorrhage, diffuse axonal injury) involves structural damage that may appear on imaging and typically presents with more severe and prolonged symptoms. The emergency warning signs — sudden worsening headache, loss of consciousness longer than a minute, repeated vomiting, pupil asymmetry, seizure, progressive confusion — warrant immediate imaging in the emergency department.
About the author
Ricky Flores is the founder of HiWave Makers and an electrical engineer with 15+ years of experience building consumer technology at Apple, Samsung, and Texas Instruments. He writes about how kids learn to build, think, and create in a tech-saturated world. Read more at hiwavemakers.com.
Sources
- Patricios, J.S., Schneider, K.J., Dvorak, J., et al. (2023). “Consensus Statement on Concussion in Sport: The 6th International Conference on Concussion in Sport–Amsterdam, October 2022.” British Journal of Sports Medicine, 57(11), pp. 695–711. https://doi.org/10.1136/bjsports-2023-106898
- Thomas, D.G., Apps, J.N., Hoffmann, R.G., et al. (2015). “Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial.” Pediatrics, 135(2), pp. 213–223. https://doi.org/10.1542/peds.2014-0966
- Leddy, J.J., Haider, M.N., Noble, J.M., et al. (2021). “Early Subthreshold Aerobic Exercise for Sport-Related Concussion.” JAMA Pediatrics, 175(4), pp. 355–363. https://doi.org/10.1001/jamapediatrics.2020.4828
- American Academy of Neurology. (2013). “Evidence-Based Guideline Update: Evaluation and Management of Concussion in Sports.” Neurology, 80(24), pp. 2250–2257.
- Master, C.L., Bacal, D., Grady, M.F., et al. (2020). “Vision and Concussion: Symptoms, Signs, Evaluation and Treatment.” Pediatrics, 145(1). https://doi.org/10.1542/peds.2019-0737
- McCrory, P., Meeuwisse, W., Dvorak, J., et al. (2017). “Consensus Statement on Concussion in Sport — The 5th International Conference on Concussion in Sport Held in Berlin, October 2016.” British Journal of Sports Medicine, 51(11), pp. 838–847.
- Echemendia, R.J., et al. (2021). “The Sport Concussion Assessment Tool 6th Edition (SCAT6).” British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2021-105263
