Graduated return to play (GRTP)

GRTP programme

All players who have a suspected or diagnosed concussion must follow a graduated return to play programme (GRTP). This GRTP starts after the minimum rest period AND if symptom free at rest.

The principle of the GRTP is to ensure that increasing levels of activity do not provoke a recurrence of the symptoms of concussion in the player. The player may progress to a new stage every 24-48 hours provided that the current stage does not provoke symptoms. All involved in the process of concussion management must be vigilant for the return of symptoms.

The GRTP programme contains six distinct stages:

  • The first stage is the recommended rest period;
  • The next four stages are training-based restricted activity;
  • Stage 6 is a return to play.

Under the GRTP programme, the player can proceed to the next stage only if there are no symptoms of concussion during rest and at the level of exercise achieved in the previous GRTP stage.

If any symptoms occur while going through the GRTP programme, the player must return to the previous stage and attempt to progress again after a minimum 24-hour period of rest without symptoms.

World Rugby recommends that a medical practitioner or approved healthcare professional supervises the GRTP and confirms that the player can take part in full contacts training before entering Stage 5.

In the event that a medical practitioner or approved healthcare professional is not available to manage all stages of the GRTP, the player can be monitored by a third party but the GRTP cannot commence until after 14 days following cessation of symptoms. Students must have returned to school and full studies before recommencing exercise.

In the extreme and rare situation where a player cannot access a medical practitioner for clearance to resume full contact practice, the Union responsible for the player must put in place processes to ensure that the player will only resume full contact process when it is safe to do so.

GRTP protocol

Each stage of the GRTP protocol is a minimum of 24 hours.

StageRehabilitation stageExercise allowedObjective
1Initial Rest (Physical and Cognitive)No driving or exercise. Minimise screen time. Consider time off or adaptation of work or study.Recovery
2a Symptoms persist at 24 hoursSymptom-limited activitiesInitially activities of daily living that do not provoke symptoms. Consider time off or adaptation of work or study.Return to normal activities (as symptoms permit)
2b Symptom free at 24 hoursLight aerobic exerciseLight jogging for 10-15 minutes, swimming or stationary cycling at low to moderate intensity. No resistance training. Symptom-free during full 24-hour periodIncrease heart rate
3Sport-specific exerciseRunning drills. No head impact activitiesAdd movement
4Non-contact training drillsProgression to more complex training drills, e.g. passing drills. May start progressive resistance trainingExercise, coordination, and cognitive load A return to learning must be achieved before returning to sport
5Full contact practiceFollowing medical clearance, participate in normal training activitiesRestore confidence and assess functional skills by coaching staff
6Return to sportNormal game play

Examples of GRTP stages

This video gives you an idea of the types of exercises that would be appropriate to each stage of the GRTP.

The player's coach is seen here overseeing the process.