Return to Learn and Return to Physical Activity Stages

• Stage 1- Activities of Daily Living and Relative Rest are the same for Return to Learn and Return to Physical Activity. These should start at the same time and should not take more than 1 - 2 days.
  • In Stage 1, resting completely for more than two days is not suggested and a complete absence from the school environment for more than one week is not recommended.
• After Stage 1 a student should Return to School as soon as they can tolerate the school environment even if they are not symptom-free. (This can be as early as Stage 2 and should not be later than Stage 3.)
  • If a student is experiencing symptoms, encourage a short break and provide accommodations.
  • While symptomatic, students may participate in low-risk activities to support recovery. Low-risk activities are those that do not put students at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared by a physician or nurse practitioner. Students may do walking, light jogging, or stationary biking as an alternative to physical education class.
  • Another blow to the head may complicate the injury further and result in a longer recovery time (i.e., higher risk of persisting symptoms). Severe brain swelling, or cerebral edema, after a concussion is very rare but potentially fatal.
• For most students, concussion-related symptoms improve within two to four weeks. Some students have a higher risk of taking a longer time to heal after their concussion. If symptoms are not improving or last longer than two to four weeks, suggest that the student return for a repeat medical assessment and a referral to interdisciplinary professionals to support their recovery.
• This tool is a guide and should not replace medical advice.

It is common and ok for a student’s symptoms to return or worsen mildly and briefly as they progress through the Return to Learn Stages, as long as returning or worsening symptoms do not last for more than an hour.

• If a student’s concussion-related symptoms return or worsen for more than an hour, the student should take a break, and the activities should be adapted.
• A student may need accommodations to tolerate:
  • cognitive activities (e.g., access to breaks, extra time to complete work); and
  • the school environment (e.g., permission to wear sunglasses in class if required or a quiet place to eat lunch)

Goal: Take more rest, if needed, in first one to two days. Encourage gentle activity. Avoid sports.

Examples of activities at this stage:

• Moving around the home and light walking
• Short games/activities (e.g., puzzles, board games, drawing, crafts)
• Social interaction (e.g., with family, friends)
• Minimize screen time (e.g., phone, TV, computer/tablet)

Ready for the next stage? The student can progress to Stage 2 if:

• they have been diagnosed with a concussion by a medical doctor or nurse practitioner; and
• it has been a maximum of one to two days after the initial injury.

Goal: Increase tolerance to cognitive activities and school environments (as appropriate)

Examples of activities at this stage:

• Gradual reintroduction of light cognitive activities (e.g., reading, short periods of schoolwork/ activities with frequent breaks) as tolerated.
• Accommodations (e.g., access to breaks, additional time to complete work, dim lighting) may be required for cognitive activities and/or to help the student to tolerate the school environment.
• Continue to prioritize social interactions (e.g., with peers and family); this is preferably done at school
• Start with shorter periods of screen time (e.g., phone, TV, computer/tablet) and build up as tolerated.
• Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Ready for the next stage? The student can progress to stage 3 if they can tolerate the activities in Stage 2.

Goal: Continue to increase tolerance for cognitive activities and exposure to the school environment. Gradual increase of time spent on activities and of the types of activities in which students can participate. Gradual reduction of concussion-related accommodations.

Examples of activities at this stage:

• Continued progression of cognitive activities (e.g., schoolwork) and exposure to the school environment (interacting with family and friends, exposure to noise/lighting) as tolerated.
• Continued increased use of screened devices (as tolerated).
• Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Ready for the next stage? The student can progress to stage 4 if they can tolerate full days of cognitive activities and the school environment without accommodations for concussion.

Note: A student should not return to physical activities with a risk of contact until they are medically cleared by a medical doctor or nurse practitioner and they have completely returned to school without concussion-related accommodations (i.e., completed Stage 4 of Return to Learn).

During Stages 1, 2 or 3 (prior to medical clearance) it is common and OK for a student’s symptoms to return or worsen mildly and briefly as long as these symptoms do not last for more than an hour.

If a student’s concussion-related symptoms worsen for longer than an hour or they cannot tolerate their symptoms the student should stop the activity and try again the next day at the same stage.

Goal: Take more rest, if needed, in first one to two days. Encourage gentle activity. Avoid sports.

Examples of activities at this Stage:

• Moving around the home and light walking
• Short games/activities (e.g., puzzles, board games, drawing, crafts)
• Social interaction (e.g., with family, friends)
• Minimize screen time (e.g., phone, TV, computer/tablet)

Ready for the next Stage? The student can progress to Stage 2 if:

• they have been diagnosed with a concussion by a medical doctor or nurse practitioner; and
• it has been a maximum of 1-2 days after the initial injury.

Goal: Increase the heart rate and gradually increase the intensity of aerobic activities and exercises that can be done individually in a predictable and controlled environment with a low risk of inadvertent head impacts.

Examples of activities at this stage:

• Gradual reintroduction of light aerobic activity/exercise (as tolerated) (e.g., low impact aerobic circuits, slow to medium pace movement)
• Gradually increase the intensity of aerobic activity/exercise to moderate effort (e.g., fitness activities, walking/rolling/swimming at a pace that causes some increase in breathing/heart rate but not enough to prevent a student from carrying on a conversation comfortably).
• May begin light resistance training (e.g., resistance bands, light weights in a controlled environment).
• Activities should be supervised/monitored by parents/guardians, teacher/supervisor/coach.
• Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Ready for the next Stage? The student can progress to Stage 3 if the student:

• has been at Stage 2 for one day or more; and
• can tolerate moderate intensity aerobic activity.

Goal: Continue to increase the intensity of aerobic activities/exercise and introduce activity/sport-specific movements and changing directions.

Examples of activities at this stage:

• Add individual movement skills/sport-specific activities (e.g., passing to a wall/partner, throwing/catching drills, individual sequence activities).
• Activities should be supervised/monitored by parents/guardians or teacher/supervisor/coach.
• Avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body until they are fully recovered and have been medically cleared.

Ready for the next Stage? A student continues to progress at Stage 3 until they:

• are symptom-free from concussion-related symptoms at rest and at full physical exertion, and
• have completed the Return to Learn Stages.

Note: A student should not return to activities with risk of contact (Stage 4) until they have obtained written medical clearance from a medical doctor or nurse practitioner.

During Stages 4, 5, or 6 (after medical clearance) a student’s concussion-related symptoms should not return. If they do, the student should return to Return to Physical Activity - Stage 3 (i.e., avoid any activity that puts the student at risk of falling or experiencing another impact to the head, neck, or body) and be reassessed by a medical doctor or nurse practitioner.

Goal: Adjust to usual intensity activity/exercise and add in more challenging skill progressions and multi-student activities/drills.

Examples of activities at this stage:

• All activities from Stage 3
• Participation in components of physical activities in physical education class or intramural programs (including partner/group activities) with low risk of body contact (e.g., multi-student passing activities/drills).
• Avoid scrimmages, gameplay, and any activity that involves body contact (e.g., checking/tackling).

Ready for the next Stage? The student can progress to Stage 5 if:

• they have been at Stage 4 for one day or more; and
• Stage 4 activities do not result in the return of concussion-related symptoms.

Goal: Restore game-play confidence and physical and mental conditioning.

Examples of activities at this stage:

• Return to full participation in physical education class, non-competitive intramural activities, and interschool practices (including contact drills, scrimmages).
• Avoid competitions.

Ready for the next stage? The student can progress to Stage 6 if they have been at Stage 5 for one day or more and Stage 5 activities do not result in the return of concussion-related symptoms.