Research in Focus | Concussion Return-to-Play Protocols Across FIFA Member Associations

A recent paper published in the Journal of Science and Medicine in Sport has provided one of the most comprehensive reviews to date of concussion return-to-play (RTP) protocols across FIFA Member Associations (MAs). The findings provide both encouragement and constructive insights that may help inform improved practice. While concussion management is now clearly recognised as an important issue within world football, the practical implementation of concussion care remains highly variable across organisations and countries.

The study reviewed concussion-related information from 95 FIFA Member Associations and found that 73 had formal RTP protocols in place. However, despite broad agreement around a six-stage return-to-play framework, there were still major differences in how concussion management was implemented in practice.

Some organisations recommended “relative rest” immediately after concussion, allowing light daily activity provided symptoms did not significantly worsen, which is consistent with current recommendations at Your Brain Health. Others still recommended complete physical and cognitive rest. Some protocols allowed progression through rehabilitation stages despite mild symptom aggravation, while others required athletes to be completely symptom-free before advancing.

The differences in return-to-play timing were particularly striking. Across the protocols reviewed, total stand-down periods ranged from as little as 30 hours to as long as 23 days. While many organisations followed FIFA or international consensus guidance recommending approximately one week between injury and return-to-play, the paper highlights growing evidence suggesting that recovery timelines are often substantially longer, particularly in women, amateur athletes, and non-elite populations.

There was also substantial variability in who was permitted to provide medical clearance. Some organisations required specialist concussion expertise or neurologist review, whereas others allowed clearance by general practitioners, nurses, or team medical staff. One protocol even permitted coaching staff involvement in assessing return-to-play readiness.

Another important finding was the inconsistent approach to return-to-learn and return-to-work pathways. Some organisations integrated these directly alongside return-to-play progression, while others treated them as entirely separate processes or provided minimal guidance. This is highly relevant as concussion management increasingly extends beyond sport participation alone and into broader educational, occupational, and psychosocial functioning.

Interestingly, only 38% of protocols mentioned baseline testing. Given the growing interest in personalised concussion care, this raises important questions regarding the future role of multimodal preseason screening and longitudinal athlete profiling. Increasingly, clinicians are recognising that concussion recovery may be influenced by individual factors extending well beyond symptom checklists alone, including vestibular and oculomotor function, sleep, mental health, fatigue, exercise tolerance, and previous injury history. These factors may also assist in informing assessments and supporting long-term brain health surveillance.

The paper also highlighted major disparities in access and transparency. Many protocols were difficult to locate publicly, and significant regional differences existed between confederations. UEFA Member Associations had the highest availability of concussion-related information online, whereas much lower levels of accessible information were identified across some other regions, likely reflecting broader differences in infrastructure and resources.

Importantly, the authors emphasise that these inconsistencies do not necessarily reflect poor practice. Rather, they may reflect differing resources, healthcare systems, medical staffing structures, cultural attitudes toward concussion, and varying interpretations of evolving evidence. However, the findings do reinforce an important reality: the challenge in football is no longer simply recognising concussion — the challenge is implementing consistent, scalable, evidence-informed brain health pathways across vastly different sporting environments.

This may represent the next major frontier in sports medicine.

Modern concussion care is increasingly moving beyond isolated “sideline diagnosis” models toward broader longitudinal brain health frameworks. Football organisations are now facing growing pressure to integrate education, digital workflows, clinician communication, symptom tracking, mental health screening, rehabilitation monitoring, and return-to-play governance into cohesive systems that function across elite, semi-professional, amateur, youth, and community sport.

Ultimately, this impressive paper raises a much broader question than concussion protocols alone:

How does football build real-world brain health systems that are practical, scalable, evidence-based, and adaptable across different sporting cultures and healthcare environments?

This will no doubt become one of the defining priorities in sports medicine over the next decade. In just a few weeks, 48 countries will compete across 104 games at the FIFA World Cup Finals. While we respect and admire different playing styles, cultures, and training philosophies across the globe, it is encouraging to think that we can also strive toward more consistent best-practice brain health and concussion care for players at all levels of the game.