Return to Learn (RTL) and Return to Sport (RTS) Protocols for Youth Athletes and Our Proposed Coordinated Return Protocol


By Steven Horwitz, D.C.  @DrHorwitz, Nash Anderson, D.C. @Sportmednews and Randy Naidoo M.D. @RandyNaidoo

Concussions have become the noteworthy safety issue in sports today. Between “1.1 and 1.9 million sports and recreation related concussions occur annually in US children aged ≤18 years”1. With this notoriety comes an unfortunate melange of terms and care standards.2  The term “concussion protocol” has been adopted by the media, collegiate/professional/Olympic sports bodies, and the medical profession, all without a standardized definition and a frequent failure by sports organizations to follow established guidelines.3 Poor parent and athlete medical literacy, inflated perceived knowledge of coaches, mixed knowledge of medical professionals, and inconsistencies in state concussion laws add to the confusion. Broadly speaking, the term concussion protocol includes both remove from play (RFP) and return to play or sport (RTS). In the current literature, two separate and distinct protocols are suggested: Return to Sport (RTS) and Return to Learn (RTL).4 The aim of this article is to provide a stimulus for discussion about consistent terminology for and an appropriate methodology of integrating RTL and RTS.

Current state of Return to Learn (RTL) / Return To Sport (RTS) Literature and guidelines

The 2016 Consensus Statement deemed youth a “special population” that “requires special paradigms”2 with regard to RTS and RTL guidelines. The literature describes “graduated return to play protocols”5 which currently guide clinical decision making.  Unfortunately, “limited research attention has been paid to the effects of concussion on objective measures of academics.”4  Clinically, the challenges of RTL are frequently missed by parents, guardians, teachers, coaches, administrators, and medical providers because of lack of education, lack of a team approach, and lack of communication.4

There is a current separation in the literature in regards to RTS and RTL as they are written as separate and distinct protocols. The consensus statement recommends that children and adolescents “should not return to sport until they have successfully returned to school. Early introduction of symptom-limited physical activity is appropriate”2 and “early physical activity in the acute phase (0-7 days) following a concussion may decrease the time needed for symptom resolution compared to strict rest.”6 The youth athlete should not return to sport until they have successfully returned to school yet may concurrently begin “symptom-limited physical activity”. Given the almost non-existent  access to sideline medical providers,  the potentially devastating outcome of second impact syndrome, and the “lack of clarity around this issue”7, the secondary prevention strategy of a dovetailed return plan is crucial.

Our proposed coordinated return approach

Our RETURN Guidelines have 6 stages: (see PDF Table 1 here: BJSM RTL RTS Table 1 03-13-2018)

  • Stage 1: Quiet Brain, Quiet Body
  • Stage 2: Gently Active Brain, Gently Active Body
  • Stage 3: Moderately Active Brain, Moderately Active Body
  • Stage 4: Active Brain, Active Body
  • Stage 5: Vigorously Active Brain, Vigorously Active Body
  • Stage 6: Full Return to Learn and Sport

The components of each stage include:

  • School Activity
  • Physical/Sport Activity
  • Support System (“Return Team”)
  • Documentation
  • Progression

There are a number of variables that should be taken into consideration when deciding how one should move between the various stages with an initial period of  24 – 48 hours preceding Stage 1. This provides time for proper medical assessment, proper documentation, proper communication to all stakeholders, and time for the development of a rigorous concussion plan. There should be a minimum of 24 hours between stages. If any concussion-related symptoms occur during the stepwise approach, the athlete should drop back to the previous asymptomatic level and attempt to progress again after being free of concussion-related symptoms (i.e. decrease in Concussion Symptom Evaluation Score) for a further 24-hour period at the lower level. Medical oversight of each stage is strongly suggested, but may not be available. At minimum a final examination of the athlete after the return protocol has been completed is mandatory.

The  support system or “Return Team” is an area that needs more attention, instruction, and coordination. Many parents feel unsupported by school personnel when navigating their child’s return to academics post-concussion and most schools do not have formalized RTL guidelines in place. Parents, teachers, administrators, and school nurses have commonly requested more training to support RTL transitions post-concussion.4

The 2016 Return to Sport Consensus calls for a standardized approach to definitions and outcomes reporting.8 Future interventions must include improved data collection of youth sports brain injuries, safety systems designed for easy implementation, and coordination of all stakeholder involvement in the healing of the athlete. The contribution of this paper is the proposal of a single return protocol which includes education for, communication amongst, and documentation provided for all members of the support system: parents, athletes, teachers, administrators, coaches, and medical providers.

This guideline is simple and well suited to our current evidence base on RTS and RTL. We as authors understand that this is a preliminary model of tapering RTL /RTS based on current best evidence. In time, as the understanding of concussion grows, this model must be modified and adapted as is appropriate. DELPHI studies with panels of youth concussion experts such as the Berlin concussion consensus may be a useful medium to facilitate this concept.

The clinical benefit is protecting and guiding the recovery our most priceless resource: our youth.


Steven Horwitz, Dallas Sports Academy, Rockwall, Texas, USA

Nash Anderson,Enhance Healthcare, Canberra, Australia

Randy Naidoo, Shine Pediatrics, Richardson, Texas, USA

Correspondence to:

Dr. Steven Horwitz, Dallas Sports Academy, Rockwall, TX 75087, USA


SH wrote the initial draft with further revisions and edits from NA, RN.

Competing interests:

SH receives income from two small self-employment businesses: Worldwide Sports Safety LLC and Deserve Victory LLC.


  1. Bryan, M, Rowhani-Rahbar, A, Comstock, R, et al. Sports- and Recreation-Related Concussions in US Youth. Pediatrics, Jul 2016, 138 (1) e20154635
  2. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847. doi: 10.1136/bjsports-2017-097699
  3. Cusimano, M, Casey, J, Jing, R, et al. Assessment of Head Collision Events During the 2014 FIFA World Cup Tournament. JAMA. 2017 Jun 27;317(24):2548-2549
  4. Lopez, A, Shnayder, M, Pomares, B, et al. Academic Accommodations for a Countywide Concussion High School Program. The Sport Journal. 2017 Dec 28; 19
  5. Russell, K, Hutchison, M, Selci, E. Academic Outcomes in High-School Students after a Concussion: A Retrospective Population-Based Analysis. PLoS One. 2016; 11(10): e0165116..
  6. Lempke L, Jaffri A, Erdman N. The Effects of Early Physical Activity Compared to Early Physical Rest on Concussion Symptoms. J Sport Rehabil. 2017 Sep 27:1-18. doi: 10.1123/jsr.2017-0217.
  7. Halstead, M, McAvoy, K, Devore, C, et al. Returning to Learning Following a Concussion. Pediatrics. 2013 Nov;132(5):948-57. doi: 10.1542/peds.2013-2867. Epub 2013 Oct 2
  8. Ardern C, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016 Jul;50(14):853-64. doi: 10.1136/bjsports-2016-096278. Epub 2016 May 25

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