Concussion Return to Play Protocol: Steps for Basketball Coaches

Concussion return to play protocol for youth and high school coaches: the signs to spot, removing a player, who clears him and the six steps back to games.

A concussion return to play protocol has the coach spot the signs, pull the player at once with no return that day, send him to a doctor, and bring him back only through six graded steps with a doctor's clearance, and this guide sets out each step, both published versions and who does what.

A concussion return to play protocol is the sequence a team follows after a player may have hurt his brain. The coach spots the signs, takes the player out of the game right away, keeps him out for the rest of the day and sends him to a doctor. The player then climbs back through six graded steps, from rest to full games, and does not take contact again until a doctor clears him. This page lays out that protocol for a youth or high school coach, from the sideline check to the last step.

This is coaching information, not medical advice. Diagnosis and clearance belong to a doctor. Follow your state or province law, your league or school policy and the doctor's instructions, which come before anything on this page. Where published versions of the return to play steps differ, both are shown.

Recognize, remove, refer. Any one sign is enough to suspect a concussion, and the player does not need to be knocked out. He comes out at once, is not left alone, sees a doctor and does not play again that day. The way back is six steps, each taking at least one day, with a doctor's clearance before contact.

What a Concussion Is

A concussion is an injury to the brain. Routine scans and x-rays do not show it. It affects how a player thinks and remembers, and the symptoms vary a lot from one player to the next.

Cause. Any hit to the head, the face or the neck can cause one. A hit elsewhere on the body can too, if it snaps the head suddenly.
No knockout needed. A player who stayed conscious the whole time can still be concussed.
The hit need not land on the head. Believing a child is safe because nothing struck his head is listed as a myth.
Symptoms can be slow. They can take time to appear, and they can get worse later the same day or that night.

Basketball injuries in general are on basketball recovery and injury prevention. A program-wide plan for injuries is on handling injuries and recovery.

Concussion Signs and Symptoms: What to Look For

The Concussion in Sport Group's pocket recognition tool says to suspect a concussion when one or more of its warning signs appear. It checks three things.

1. What you can see

Not responding, or knocked out
Lying still on the floor, or slow getting up
Grabbing or clutching his head
Unsteady, losing balance, falling over or poorly coordinated
Confused, or unaware of plays or events
A dazed, blank or vacant look

2. What the player reports or shows

Any one of these may point to a concussion.

Body and senses	Thinking	Mood and energy
Headache, dizziness, "pressure in head," neck pain, nausea or vomiting, blurred vision, sensitivity to light, sensitivity to noise, balance problems, seizure or convulsion, loss of consciousness	Confusion, feeling slowed down, feeling like "in a fog," amnesia, difficulty remembering, difficulty concentrating	Drowsiness, fatigue or low energy, more emotional, irritability, sadness, nervous or anxious, "don't feel right"

The three columns are our grouping. The items are the tool's. A second published list sorts the signs another way:

Thinking problems. Does not know the time, date, place, period, opponent or score, general confusion, cannot recall what happened just before and after the hit, knocked out.
What the athlete complains of. Headache, dizziness, feeling dazed, feeling "dinged" or stunned, seeing stars or flashing lights, ringing ears, sleepiness, loss of vision, double or blurry vision, stomachache or nausea.
Other problems. Poor coordination or balance, a blank or glassy stare, vomiting, slurred speech, slow to answer or follow directions, easily distracted, poor concentration, odd emotions such as laughing, crying or getting mad easily, and not playing as well.

3. Memory questions

The tool lists five questions. Missing any one of them suggests a concussion, so the player comes out.

"At what venue are we at today?"
"Which half is it now?"
"Who scored last in this game?"
"What team did you play last week / game?"
"Did your team win the last game?"

Remove the Player Right Away

The published guidance agrees on the first move. A player with a suspected concussion comes out immediately.

Out until assessed. He stays out of all activity until he has a medical assessment. Every suspected case should go to a medical professional, who diagnoses it and makes the return decisions, even if the symptoms clear up.
No return that day. He does not go back in that day, even if he says he feels fine, because a head injury can worsen in the hours after, that same day or night.
Not left alone, not driving. He should not be left alone, and he should not drive.
A doctor that day. A doctor should see him that same day, as soon as possible.
His own judgment may be off. A concussed player may not be able to judge how hurt he is.

For the doubtful case the short rule is "when in doubt, sit them out." Its partner is "when in doubt, check them out": if you are not sure whether a child is concussed or recovering as he should, see a doctor.

Red Flags: Call for Help

If any of these is reported, take the player off the floor safely and at once. If no qualified medical professional is there, the recognition tool says to consider an ambulance for urgent assessment.

Neck pain
Double vision
Severe or increasing headache
Repeated vomiting
Seizure or convulsion
Increasing confusion or irritability
Weakness, tingling or burning in the arms or legs
Getting less and less conscious
An unusual change in behaviour

A player who has been knocked out goes to hospital by ambulance. Leave him where he is and leave any equipment, such as a helmet, on him, since his neck may be hurt too, and wait for the paramedics. Basic first aid comes first (danger, response, airway, breathing, circulation). Unless you are trained, do not move him except to support his airway.

Who Clears a Player

A doctor does. The coach recognizes and removes, and the doctor diagnoses and clears. The doctor comes in at three points on the way back.

Before the steps start. The player rests until his symptoms are gone, then sees a doctor before the graded steps begin. A doctor with concussion experience is preferred.
Before contact. Contact practice (step 5) waits for medical clearance in every published version.
Before games. He returns to play only once he has come through the steps symptom-free and a doctor has cleared him.

At the visit the doctor may ask about earlier concussions and the player's sport history, test his orientation, memory and attention, and check his balance and coordination. A CT or MRI may be ordered if there is a worry about bleeding or another structural injury. The concussion itself does not appear on those scans.

One published version of the steps was written for children older than 10. It says younger children may need their own guidelines and more cautious care, and that the return decision rests with the physician. Repeated concussions may mean a child's activities change or stop for good, on a physician's advice.

The Concussion Return to Play Protocol, Step by Step

Both published versions use the same six steps, from rest to game play, and both say each step takes at least one day. They differ in the detail inside each step and in where the doctor comes in.

Step	Timed version	Supervised version
1. Rest	No activity at all. Go on to step 2 when he is back to normal and a doctor has cleared him.	Full rest, with less school, work and anything that takes concentration. No exercise until the symptoms are gone. A physician, ideally one experienced with concussions, sees him before step 2.
2. Light aerobic exercise	Walking or a stationary bike, 10 to 15 minutes.	Walking or a stationary bike, with someone supervising who can watch for symptoms. No weights or resistance work. Time and effort can build slowly if nothing comes back during the session or the next day.
3. Sport-specific activity	Aerobic work in the sport for 20 to 30 minutes. No contact.	Sport skills such as skating or throwing. No body contact and no jarring moves such as high-speed stops.
4. Drills without contact	Practice such as ball drills and shooting drills, still with no contact.	Drills with no body contact. How long this takes depends on the injury and the player. Step 5 waits for medical clearance.
5. Drills with contact	Contact practice, after a doctor clears him.	Drills with body contact.
6. Game play	Game play.	Game play.

The steps are not days. The supervised version says one step can take many days, especially after a severe concussion. It states the rule in capitals: never return to play with symptoms. A player who comes back before he has fully recovered is at high risk of a second concussion, and its symptoms may be stronger and longer lasting.

The published steps use hockey and soccer examples (skating, running, no checking, no heading the ball). Ball drills and shooting drills are the timed version's own examples for step 4. Ask the doctor which basketball activities fit each step for your player.

If Symptoms Come Back During the Steps

The steps can bring symptoms back. That means the brain has not healed and needs more rest, and the symptoms may come back later that day or the next day, not only during the activity. Every version stops the player. They give different rules for what happens next.

Version	What happens
Drop back a step	Stop, wait 24 to 48 hours, then pick up again at the step before.
Rest a day, doctor before restarting	Stop at once and rest until symptoms are gone, for at least 24 hours. Get a doctor's clearance before the steps start over.
Doctor check before any activity	Stop and rest until symptoms are gone. A physician must re-evaluate the player before he tries any activity again. When symptoms appear, rest until they clear, then let one more full day pass before any activity, and see a physician if they last.
Rest until clear	Stop and rest until symptoms are gone before trying any activity again, and see a physician if they last.

Because these rules differ, follow the one your league, school or the player's doctor uses. Putting program policies in writing is covered on basketball team rules.

Return to School

School and screens count as part of the rest. Keeping a child out of sport but letting him do everything else is listed as a myth, because he needs mental rest as well as physical rest.

Mental rest. Cut back on classes, reading, texting, TV, computer work and video games. Driving is on the athlete's list too.
When to go back. Once he feels better and being in class does not stir up his symptoms. Another version waits until the symptoms have eased a lot, in consultation with the health care professional.
Part-time first. Start with part days, half days in one version, and move to full days if that goes well.
Stay home if it gets worse. A child whose symptoms worsen in class stays home.

The published guidance does not set a fixed order between finishing the school return and starting the sport steps. Ask the doctor.

What Coaches, Parents and Athletes Each Do

Person	Job
Coach or trainer	Spots the signs, takes the player out at once, does not leave him alone, gets him to a doctor that day, calls an ambulance if he is knocked out, allows no same-day return and no return until a doctor has seen him, and needs a doctor's clearance before games.
Athlete	Stops playing, tells a coach, trainer, parent or another responsible adult, does not drive, rests and does not hide symptoms. One slogan for players is "Don't hide it, report it."
Parent	Gets the child to a doctor, keeps him resting at home, handles the part-time school return and checks on him through the night after the injury. Wake him if his breathing or sleep is a worry, otherwise let him sleep. No return to sport until a doctor clears him.
Doctor	Diagnoses, decides when the steps can start, clears contact and clears the return to play.

Return to the doctor right away if, once diagnosed, the player gets more confused, has a headache that keeps getting worse, vomits more than twice, cannot be woken, has any trouble walking, has a seizure or behaves strangely. Ways to get this to parents are on basketball parent communication and the basketball parent meeting agenda. The parent's side of the season is on the role of parents in youth basketball and the youth sports parents guide.

Parents are also asked to model safe behaviour, since children copy it, and to teach respect for the rules and good sportsmanship. More on running a youth team is on coaching youth basketball, and game-day jobs for the adults are on the adult roles at a youth game.

How long recovery takes

Signs and symptoms commonly last 7 to 10 days, and can last far longer. Some athletes need many weeks or months. A history of concussions may mean a longer recovery. The time spent on non-contact work varies with how bad the injury was and with the player.

Check the current version

The recognition tool on this page is the 2013 edition. Use the current concussion policy and forms your league, school or state or province requires, and the doctor's written clearance, over anything here.

Questions Coaches Ask

What is the concussion protocol in basketball?

Recognize the signs, remove the player right away with no return that day, have him seen by a doctor, then bring him back through six graded steps: rest, light aerobic exercise, sport-specific activity, drills without contact, drills with contact after a doctor's clearance, and game play. Your league or school may have its own written protocol, which comes first.

How long is return to play after a concussion?

Each of the six steps takes at least one day, and one step can take many days. Symptoms commonly last 7 to 10 days and can last weeks or months. The steps do not start until the player is symptom-free at rest and has seen a doctor.

What are concussion signs and symptoms?

Watch for a player who is slow to get up, unsteady, clutching his head, dazed or confused about the play. He may report headache, dizziness, nausea, blurry vision, light or noise bothering him, feeling foggy, or that he does not "feel right." Missing simple memory questions about the game is another sign. One sign is enough to take him out.

Can a player go back in the same game after a head injury if he feels fine?

No. There is no same-day return even when the player says he feels better, because the effects can grow worse later the same day or night.

Does a player have to be knocked out to have a concussion?

No. A player can be concussed without ever losing consciousness.

Who can clear a player to return after a concussion?

A doctor, preferably one with concussion experience. The doctor sees the player before the steps begin and clears him again before contact. Your state or province and your league may set who can sign the clearance.

What happens if symptoms come back during return to play?

The player stops. Then the versions differ: one waits 24 to 48 hours and drops back a step, another rests at least 24 hours and needs a doctor's clearance to restart, and a third requires a physician re-check before any activity. Follow the one your league, school or doctor uses.

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