Cognitive Rest Guidelines

What does “cognitive rest” mean?

According to the CDC, rest and careful management of physical and cognitive exertion are the keys to recovery. Cognitive activity includes heavy concentration or focus, visual stress, memory, reasoning, reading or writing (e.g., texting, television, video games, computer use, homework, classwork, job-related activity).

Until a full recovery is achieved, your child or teen may need the following adjustments to home activities:

  • Limitation of television, texting, computers, video games
  • Avoidance of noisy and/or visually stimulating environments (movie theaters, malls, restaurants, grocery stores, audience participation of on-field sports, etc.)
  • Avoidance of physical exertion (walking, jogging, dancing, weight-lifting, spinning rides, biking, sports of any kind, etc.)

The treating physician will tailor your child or teen’s cognitive rest guidelines according to their exam.

What are the “Return To School” guidelines?

Once the physician determines that it is safe for your child or teen to resume academic activities, any of the following adjustments may be recommended based on the patient’s exam:

  • Shortened day
  • Shortened classes or frequent rest breaks
  • Reduced homework load
  • Extended time to complete coursework
  • Delayed participation in math class
  • No classroom or standardized testing
  • No timed tests
  • Avoidance of Smart Board or computer lab
  • Avoidance of noisy environments (lunchroom, group passage in halls, bus transportation)
  • Avoidance of physical exertion (stairs, gym, sports)

What is the “Five Stages Return To Play” Protocol?

When your child or teen is asymptomatic at rest and during academic activities, the physician will recommend a supervised “Five Stages Return to Play” protocol as follows:

Five Stages Return To Play Protocol
Day 1: LIGHT AEROBIC EXERCISE for 20-30 minutes (goal: increase HR): low stimulus environment, no impact activities, limit head movement/position change, limit concentration activities
  • Light aerobic conditioning (walking at rate 2.5 mi/h; stationary bike)
  • Sub-max strengthening
  • ROM/stretching
  • Very low level balance activities
Day 2: MODERATE AEROBIC EXERCISE for 20-30 minutes (goal: increase HR): perform in gym areas, use various exercise equipment, allow some positional changes and head movement, low level concentration activities
  • Moderate aerobic conditioning (jogging , swimming)
  • Light weight strength exercise
  • Stretching (active stretching initiated)
  • Low level balance activities
Day 3: SPORT-SPECIFIC EXERCISE for 20-30 minutes (goal: add movement): any environment ok for exercise (indoor/outdoor), integrate strength, conditioning and balance proprioceptive exercise, incorporate concentration challenges 
  • Moderately aggressive aerobic exercise (runningskating, cycling)
  • Active stretching exercise
  • Challenging proprio-balance activities
  • No contact, no head impact activities
Day 4: SPORTS-SPECIFIC PRACTICE DRILLS (goal: add coordination, cognitive load): continue to avoid contact activity, resume aggressive training in all environments 
  • Non-contact physical training (passing, running, and skating drills)
  • Progressive strength and resistance training
  • Impact activities, plyometrics
  • Sport specific activities


Day 5: POST- RTP EVALUATION: Return to Medical professional 


  • Post- exercise ImPACT test and physical exam to determine readiness and clearance for sports

If headaches, dizziness, or other symptoms occur during any step, the activity needs to be stopped. The athlete should then wait 24 hours and start at the previous level again.