New Graduated Return to Play Guidelines in Rugby

At the recent Sports Performance and Prevention Conference we presented on the therapeutic role that exercise has to play in the management of concussion. From light aerobic activity after 24 - 48 hours of rest, to the use of a sub-symptom controlled exercise program (after treadmill based testing using a modified Balke protocol) for persistent symptoms, to the graduated return play protocols.

So, what’s new in the graduated return to play protocols (GRTP)?

For practitioners involved with rugby union teams or players, NZ Rugby have issued updated concussion guidelines (see below) for the upcoming season. Whilst the actual return to play dates have not changed (still 23 days for those under 19yrs age and 21 days for those 19yrs and over), the management of players having sustained a concussion is now more in line with the changing literature on activity and its benefits 1, 2.

An initial 48-hour period of rest followed by light aerobic exercise for the next two weeks ensures that players are active but does not return them to sport specific drills any quicker. The key to light aerobic activity is that this does not provoke or exacerbate symptoms. Personally we use a +3 increase in symptom severity on a visual analog scale as an indicator of lack of tolerance to the activity (over-doing it). Following this period, players can return to sport specific training, progressing through the various stages at differing rates dependent upon age, providing they are asymptomatic. Those still symptomatic should be referred for additional management.

Prior to any return to contact-based training, players must receive a medical clearance from a registered medical practitioner. This should involve a thorough assessment including the following, with normative data providing reference ranges3:

1. Symptom score and severity score using SCAT 5 assessment tool ( <5 on each scale)
2. Neurocognitive assessment (SAC) using SCAT 5 assessment tool (>24)
3. Balance error scoring assessment (<5 errors single leg, <3 errors tandem gait)
4. Tandem gait walk test (<14 seconds)
5. Full pain-free symmetrical range of movement of the cervical spine
6. Completion of GRTP with no recurrence of symptoms (Stages 1-4)


1. Leddy J, Hinds A, Miecznikowski J, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med 2017;0.
2. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. Journal of Physical Medicine and Rehabilitation 2016:S91-S100.
3. Fuller G, Govind O, Tucker R, Raftery M. Sport concussion assessment tool—Third edition normative referencevalues for professional Rugby Union players. J Sci Med Sport 2017.