Return to activity

    • EBR (strong)128,131,13232. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      128. Leddy JJ, Burma JS, Toomey CM, Hayden A, Davis GA, Babl FE, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):762-70. doi: 10.1136/bjsports-2022-106676.
      129. Australian Government Department of Health and Aged Care. About physical activity and exercise. 2021.
      130. Clearinghouse for Sport. What is sport? 2024 [Available from: https://www.clearinghouseforsport.gov.au/kb/what-is-sport#:~:text=All%20forms%20of%20physical%20activity,in%20competition%20at%20all%20levels.
      131. Haider MN, Leddy JJ, Wilber CG, Viera KB, Bezherano I, Wilkins KJ, et al. The predictive capacity of the Buffalo Concussion Treadmill Test after sport-related concussion in adolescents. Front Neurol. 2019;10:395. doi: 10.3389/fneur.2019.00395.
      132. Willer Barry S, Haider Mohammad N, Bezherano I, Wilber Charles G, Mannix R, Kozlowski K, et al. Comparison of rest to aerobic exercise and placebo-like treatment of acute sport-related concussion in male and female adolescents. Arch Phys Med Rehabil. 2019:1-9. doi: 10.1016/j.apmr.2019.07.003.
      Adapted32
    • EBR (strong)128,131,13232. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      128. Leddy JJ, Burma JS, Toomey CM, Hayden A, Davis GA, Babl FE, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):762-70. doi: 10.1136/bjsports-2022-106676.
      129. Australian Government Department of Health and Aged Care. About physical activity and exercise. 2021.
      130. Clearinghouse for Sport. What is sport? 2024 [Available from: https://www.clearinghouseforsport.gov.au/kb/what-is-sport#:~:text=All%20forms%20of%20physical%20activity,in%20competition%20at%20all%20levels.
      131. Haider MN, Leddy JJ, Wilber CG, Viera KB, Bezherano I, Wilkins KJ, et al. The predictive capacity of the Buffalo Concussion Treadmill Test after sport-related concussion in adolescents. Front Neurol. 2019;10:395. doi: 10.3389/fneur.2019.00395.
      132. Willer Barry S, Haider Mohammad N, Bezherano I, Wilber Charles G, Mannix R, Kozlowski K, et al. Comparison of rest to aerobic exercise and placebo-like treatment of acute sport-related concussion in male and female adolescents. Arch Phys Med Rehabil. 2019:1-9. doi: 10.1016/j.apmr.2019.07.003.
      Adapted32
    • EBR (strong)128,133-1356. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.
      32. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      128. Leddy JJ, Burma JS, Toomey CM, Hayden A, Davis GA, Babl FE, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):762-70. doi: 10.1136/bjsports-2022-106676.
      133. Grool AM, Aglipay M, Momoli F, Meehan WP, 3rd, Freedman SB, Yeates KO, et al. Association between early participation in physical activity following acute concussion and persistent postconcussive
      symptoms in children and adolescents. JAMA. 2016;316(23):2504-14.
      134. Leddy JJ, Haider MN, Ellis MJ, Mannix R, Darling SR, Freitas MS, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr. 2019;173(4):319-25. doi:
      10.1001/jamapediatrics.2018.4397.
      135. Leddy JJ, Master CL, Mannix R, Wiebe DJ, Grady MF, Meehan WP, et al. Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial. Lancet Child Adolesc Health. 2021;5(11):792-9. doi: 10.1016/S2352-4642(21)00267-4.

      Adapted6,32
    • CBR12832. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      128. Leddy JJ, Burma JS, Toomey CM, Hayden A, Davis GA, Babl FE, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):762-70. doi: 10.1136/bjsports-2022-106676.
      Adopted32
    • N/A New
    • EBR (conditional)136-13829. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      136. Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed physical exertion in recovery from sports-related concussion: a randomized pilot study. Dev Neuropsychol. 2015;40(5):273-8. doi: 10.1080/87565641.2015.1067706.
      137. Remigio-Baker RA, Bailie JM, Gregory E, Cole WR, McCulloch KL, Cecchini A, et al. Activity level during acute concussion may predict symptom recovery within an active duty military population. J Head Trauma Rehabil. 2020;35(2):92-103. doi: 10.1097/HTR.0000000000000498.
      138. Brett BL, Breedlove K, McAllister TW, Broglio SP, McCrea MA, Investigators CC, et al. Investigating the range of symptom endorsement at initiation of a graduated return-to-play protocol after concussion and duration of the protocol: A study from the National Collegiate Athletic Association-Department of Defense Concussion, Assessment, Research, and Education (CARE) Consortium. Am J Sports Med. 2020;48(6):1476-84. doi: 10.1177/0363546520913252.
      Adapted29
    • EBR (strong)14032. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      140. Macnow T, Curran T, Tolliday C, Martin K, McCarthy M, Ayturk D, et al. Effect of screen time on recovery from concussion: a randomized clinical trial. JAMA Pediatr. 2021. doi: 10.1001/jamapediatrics.2021.2782.
      Adopted32
    • EBR (strong)6. Babl FE, Tavender E, Dalziel S. Australian and New Zealand guideline for mild to moderate head injuries in children – Full guideline. Melbourne: Paediatric Research in Emergency Departments International Collaborative; 2021.Adopted6
    • CBR29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      141. D’Silva L, Devos H, Hunt SL, Chen J, Smith D, Rippee MA. Concussion symptoms experienced during driving may influence driving habits. Brain Inj. 2021;35(1):59-64. doi: 10.1080/02699052.2020.1857839.
      142. Lempke LB, Lynall RC, Hoffman NL, Devos H, Schmidt JD. Slowed driving-reaction time following concussion-symptom resolution. J Sport Health Sci. 2021;10(2):145-53. doi: 10.1016/j.jshs.2020.09.005.
      143. Schmidt JD, Hoffman NL, Ranchet M, Miller LS, Tomporowski PD, Akinwuntan AE, et al. Driving after concussion: is it safe to drive after symptoms resolve? J Neurotrauma. 2017;34(8):1571-8. doi: 10.1089/neu.2016.4668.
      Adapted29
    • CBR29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      141. D’Silva L, Devos H, Hunt SL, Chen J, Smith D, Rippee MA. Concussion symptoms experienced during driving may influence driving habits. Brain Inj. 2021;35(1):59-64. doi: 10.1080/02699052.2020.1857839.
      142. Lempke LB, Lynall RC, Hoffman NL, Devos H, Schmidt JD. Slowed driving-reaction time following concussion-symptom resolution. J Sport Health Sci. 2021;10(2):145-53. doi: 10.1016/j.jshs.2020.09.005.
      143. Schmidt JD, Hoffman NL, Ranchet M, Miller LS, Tomporowski PD, Akinwuntan AE, et al. Driving after concussion: is it safe to drive after symptoms resolve? J Neurotrauma. 2017;34(8):1571-8. doi: 10.1089/neu.2016.4668.
      Adapted29
    • EBR (conditional)145-14729. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      144. Cancelliere C, Kristman VL, Cassidy JD, Hincapie CA, Cote P, Boyle E, et al. Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S201-9. doi: 10.1016/j.apmr.2013.10.010.
      145. Gourdeau J, Fingold A, Colantonio A, Mansfield E, Stergiou-Kita M. Workplace accommodations following work-related mild traumatic brain injury: what works? Disabil Rehabil. 2020;42(4):552-61. doi: 10.1080/09638288.2018.1503733.
      146. Graff HJ, Deleu NW, Christiansen P, Rytter HM. Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis. Neuropsychol Rehabil. 2021;31(9):1349-73. doi: 10.1080/09602011.2020.1778489.
      147. Howe EI, Fure SCR, Lovstad M, Enehaug H, Sagstad K, Hellstrom T, et al. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Front Neurol. 2020;11:561400. doi: 10.3389/fneur.2020.561400.
      Adapted29
    • EBR (conditional)145-14729. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
      145. Gourdeau J, Fingold A, Colantonio A, Mansfield E, Stergiou-Kita M. Workplace accommodations following work-related mild traumatic brain injury: what works? Disabil Rehabil. 2020;42(4):552-61. doi: 10.1080/09638288.2018.1503733.
      146. Graff HJ, Deleu NW, Christiansen P, Rytter HM. Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis. Neuropsychol Rehabil. 2021;31(9):1349-73. doi: 10.1080/09602011.2020.1778489.
      147. Howe EI, Fure SCR, Lovstad M, Enehaug H, Sagstad K, Hellstrom T, et al. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Front Neurol. 2020;11:561400. doi: 10.3389/fneur.2020.561400.
      Adapted29
    • CBR14829. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion
      guidelines: Guideline for concussion and prolonged symptoms for adults 18 years
      or older 2023 [Available from: https://concussionsontario.org.
      148. Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: A randomized controlled trial of emergency department discharge instructions. Acad Emerg Med. 2017;24(1):75-82. doi: 10.1111/acem.13073.
      Adopted29
    • CBR32. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      148. Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: A randomized controlled trial of emergency department discharge instructions. Acad Emerg Med. 2017;24(1):75-82. doi: 10.1111/acem.13073.
      149. Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, et al. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):798-809. doi: 10.1136/bjsports-2022-106682.
      150. CDC. CDC Heads Up: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2022 [Available from: https://www.cdc.gov/headsup/index.html.
      151. Halstead ME, Walter KD, Council on Sports M, Fitness. American Academy of Pediatrics. Clinical report–sport-related concussion in children and adolescents. Pediatrics. 2010;126(3):597-615. doi: 10.1542/peds.2010-2005.
      Adopted32
    • CBR14830. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
      148. Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive rest and graduated return to usual activities versus usual care for mild traumatic brain injury: A randomized controlled trial of emergency department discharge instructions. Acad Emerg Med. 2017;24(1):75-82. doi: 10.1111/acem.13073.
      Adapted30
    • CBR30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
      31. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853.
      Adapted30,31
    • Table 1: Return to learn strategy
      Source: Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.

    • CBR32. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.Adapted32
    • EBR (conditional)14930. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9.
      32. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Brit J Sports Med. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.
      149. Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, et al. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):798-809. doi: 10.1136/bjsports-2022-106682.
      Adapted30,32
    • EBR (conditional)152-15631. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, et al. Centers
      for Disease Control and Prevention guideline on the diagnosis and management of
      mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853.
      doi: 10.1001/jamapediatrics.2018.2853.
      152. Ransom DM, Vaughan CG, Pratson L, Sady MD, McGill CA, Gioia GA. Academic effects of concussion in children and adolescents. Pediatrics. 2015;135(6):1043-50. doi: 10.1542/peds.2014-3434.
      153. Babikian T, McArthur D, Asarnow Robert F. Predictors of 1-month and 1-year neurocognitive functioning from the UCLA longitudinal mild, uncomplicated, pediatric traumatic brain injury study. J Int Neuropsychol Soc. 2013;19(2):145-54. doi: 10.1017/S135561771200104X.
      154. Sady MD, Vaughan CG, Gioia GA. School and the concussed youth: recommendations for concussion education and management. Phys Med Rehabil Clin N Am. 2011;22(4):701-19, ix. doi: 10.1016/j.pmr.2011.08.008.
      155. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sports Med. 2015;34(2):213-31. doi: 10.1016/j.csm.2014.12.005.
      156. DeMatteo C, Stazyk K, Giglia L, Mahoney W, Singh SK, Hollenberg R, et al. A balanced protocol for return to school for children and youth following concussive injury. Clin Pediatr (Phila). 2015;54(8):783-92. doi: 10.1177/0009922814567305.
      Adapted31
    • CBR149. Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, et al. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Brit J Sports Med. 2023;57(12):798-809. doi: 10.1136/bjsports-2022-106682.New
    • StepExercise strategyActivity at each stepGoal
      1Symptom-limited activityDaily activities that do not exacerbate symptoms (e.g. walking).Gradual reintroduction of work/school
      2Aerobic exercise
      2A—Light (up to approximately 55% maxHR) then 
      2B—Moderate (up to approximately 70% maxHR)
      Stationary cycling or walking at slow to medium pace. May start light resistance training that does not result in more than mild and brief exacerbation* of concussion symptoms.Increase heart rate
      3Individual sport-specific exercise
      Note: If sport-specific training involves any risk of inadvertent head impact, medical clearance should occur prior to Step 3
      Sport-specific training away from the team environment (e.g. running, change of direction and/or individual training drills away from the team environment). No activities at risk of head impact.Add movement, change of direction
      Steps 4–6 should begin after the resolution of any symptoms, abnormalities in cognitive function and any other clinical findings related to the current concussion, including with and after physical exertion.
      4Non-contact training drillsExercise to high intensity including more challenging training drills (e.g. passing drills, multiplayer training) can integrate into a team environment.Resume usual intensity of exercise, coordination and increased thinking
      5Full contact practiceParticipate in normal training activities.Restore confidence and assess functional skills by coaching staff
      6Return to sportNormal game play.
      Table 2: Return-to-sport (RTS) strategy—each step typically takes a minimum of 24 hours
      Notes:  *Mild and brief exacerbation of symptoms (i.e. an increase of no more than 2 points on a 0–10 point scale for less than an hour when compared with the baseline value reported prior to physical activity). Athletes may begin Step 1 (i.e. symptom-limited activity) within 24 hours of injury, with progression through each subsequent step typically taking a minimum of 24 hours. If more than mild exacerbation of symptoms (i.e. more than 2 points on a 0–10 scale) occurs during Steps 1–3, the athlete should stop and attempt to exercise the next day. Athletes experiencing concussion-related symptoms during Steps 4–6 should return to Step 3 to establish full resolution of symptoms with exertion before engaging in at-risk activities. Written determination of readiness to RTS should be provided by an HCP before unrestricted RTS as directed by local laws and/or sporting regulations.
      HCP=healthcare professional; maxHR=predicted maximal heart rate according to age (i.e. 220-age).
      Source: Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695-711. doi: 10.1136/bjsports-2023-106898.