General activity
Evidence suggests that people with mTBI/concussion can safely and gradually resume normal activity (activities of daily living, work, school, duty, leisure) as early as 24 hours post-injury. Strict rest until symptom resolution is not effective for recovery from mTBI/concussion. Light physical activity that does not exacerbate symptoms during the 48 hours after injury facilitates recovery.128
Transient symptoms refer to a temporal onset of symptoms related to activity that typically resolve or improve in less than 24 hours. The onset of transient symptoms during a gradual return to activity is common and safe so long as these do not impair functional abilities beyond a short time frame and no new or further injury is caused. Exacerbation of symptoms lasting greater than 24 hours indicate that tolerance thresholds have been exceeded, and activity should be adjusted accordingly. Where progress is not seen, or is very slow, a reassessment by a healthcare professional is warranted.
EBR (strong)128,131,132 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.
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)128,131,132 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.
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)128,133-135 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.
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
CBR128 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.Adopted32 N/A New EBR (conditional)136-138 29. 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 Refer to the RACGP Falls Prevention in Older Adults website or World falls guidelines 2022 for further details on assessing and managing falls risk.
EBR (strong)140 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.
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
CBR 29. 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 CBR 29. 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 Guidance on assessing medical fitness to drive is available in Australia and New Zealand.
Return to work
Evidence indicates that encouraging people to gradually and progressively (hours and duties) return to some form of meaningful work provides the opportunity for the individual to establish and maintain routine and structure to their day and their sleep schedule, to gradually build tolerance to environmental stimuli, to gradually build tolerance for physical and/or cognitive activities, and to provide a purpose for the day. Returning to meaningful activities earlier helps to promote both physical and mental recovery and results in higher likelihood of success.144
In situations where persisting symptoms were not successfully managed with an individualised treatment or rehabilitation plan, a broad variety of meaningful activities that promote recovery or provide a sense of purpose may be a consideration.
EBR (conditional)145-147 29. 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)145-147 29. 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 CBR148 29. 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
Return to school and learning
The transition back to school and learning following mTBI/concussion is an important consideration for children, adolescents and young adults. A systematic review revealed that most athletes (93%) of all ages have a full return to learning with no additional academic support by 10 days.149 The process of quickly returning to learning may be more challenging for students with specific considerations (e.g. high acute symptom severity, a prior learning disability) that may affect recovery.149
Children and adolescents, especially those studying at high school or university, may have different requirements due to the increased demands of home work and exams.150 Educational accommodations should be based on resolution of symptoms (physical, cognitive, emotional and sleep/fatigue) and age/school level of the child/youth. Accommodations may include part-time school, rest breaks, low-noise contexts, reduction in subject load, as well as the extra time in exams. These accommodations may need to extend past symptom resolution for a short period to allow the student to “catch-up” on what they have missed while coping with the demands of current learning tasks.151 The young person and family should work with the school to arrange accommodations. Most educational systems will accept recommendations from medical, allied health, and/or psychology professionals for formal process such as reasonable accommodations for exams.
CBR 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.
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 CBR148 30. 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 CBR 30. 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 Step Mental activity Activity at each step Goal 1 Daily activities that do not result in more than a mild exacerbation of symptoms Typical activities during the day (e.g. reading) while minimising screen time. Start with
5–15 min at a time and increase graduallyGradual return to typical activities 2 School activities Homework, reading or other cognitive activities outside the classroom Increase tolerance to cognitive work 3 Return to school part-time Gradual introduction of schoolwork. May need to start with a partial school day or with greater access to rest breaks during the day Increase academic activities 4 Return to school full-time Gradually progress in school activities until a full day can be tolerated without more than mild symptom exacerbation Return to full academic activities and catch up on missed work 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.
CBR 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. Adapted32
EBR (conditional)149 30. 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
The type of accommodations and their duration should be determined based on resolution of symptoms across all domains (physical, cognitive, emotional, sleep/fatigue) and the age/school level of the child/young person. Sufficient support should be put in place to allow the student to catch up on work missed and any non-essential assignments to be waived or modified. Regular contact between the student (and family) and the school about their recovery improves communitcation and understanding, ideally with a sense of partnership between the school and family.
For most students, accommodations are short term. Students requiring accommodations for more than 3-6 months should be referred to specialized concussion services or providers with experience in learning and mental health such as psychologist, educational psychologist, or neuropsychologist. The purpose is to investigate the barriers to recovery, assess any underlying learning or mental health problems, and determine the best supportive strategies.
EBR (conditional)152-156 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.
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 Online information is available on the right to education and on providing educational support to students in New South Wales, Victoria, Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory.
Return to sport
Deferring return to sport decreases the likelihood of repeat mTBI/concussion.149 Avoidance of repeated head injury increases time to recovery and decreases length of persisting symptoms.149 The graduated return to play should be individualised based on symptoms with return to sport occurring only when symptom-free in the context of all activities including school/work. While a minimum period between injury and return to sport is controversial, consultation on the matter has shown that health professionals and consumers want consistent advice across sports that is feasible to implement into current practice across Australia and Aotearoa New Zealand.
To develop a recommendation, the GDG looked at different concussion protocols across different sporting codes in Australia and Aotearoa New Zealand, most of which did not have a common ‘return to play’ strategy. The group also looked at national and international guidelines, in particular recommendations from national bodies such as the New Zealand Accident Compensation Corporation (ACC), UK government on non-elite sports, and sporting organisations such as World Rugby and AFL community guidelines.
The following consensus-based recommendations are based on the results of a delphi poll undertaken to reach consensus among the GDG. The recommendations relate to community sports and follows similar recommendations from national bodies such as the AIS, NZ ACC, UK government on non-elite sports and sporting organisations such as World Rugby and AFL community guidelines.
CBR 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. New Step Exercise strategy Activity at each step Goal 1 Symptom-limited activity Daily activities that do not exacerbate symptoms (e.g. walking). Gradual reintroduction of work/school 2 Aerobic 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 3 Individual sport-specific exercise
Note: If sport-specific training involves any risk of inadvertent head impact, medical clearance should occur prior to Step 3Sport-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. 4 Non-contact training drills Exercise 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 5 Full contact practice Participate in normal training activities. Restore confidence and assess functional skills by coaching staff 6 Return to sport Normal 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.