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.
| Stage | Rehabilitation stage | Exercise allowed | Objective |
|---|---|---|---|
| 1 | Initial 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 hours | Symptom-limited activities | Initially 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 hours | Light aerobic exercise | Light jogging for 10-15 minutes, swimming or stationary cycling at low to moderate intensity. No resistance training. Symptom-free during full 24-hour period | Increase heart rate |
| 3 | Sport-specific exercise | Running drills. No head impact activities | Add movement |
| 4 | Non-contact training drills | Progression to more complex training drills, e.g. passing drills. May start progressive resistance training | Exercise, coordination, and cognitive load A return to learning must be achieved before returning to sport |
| 5 | Full contact practice | Following medical clearance, participate in normal training activities | Restore confidence and assess functional skills by coaching staff |
| 6 | Return to sport | Normal 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.