Guidelines Quick Access
Return to 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.159
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) 159,162,163
Strict rest until the complete resolution of mTBI/concussion-related symptoms is not beneficial and not recommended.
EBR (Strong) 159,162,163
Relative (not strict) rest is recommended for 24-48 hours after mTBI/concussion. Most activities of daily living can resume immediately.
EBR (Strong) 124,159,164,165
Following mTBI/concussion, physical activity should be started between 24 and 48 hours post injury, gradually increasing from low to moderate physical activity, provided that it is at a level that does not result in significant exacerbation of post-concussive symptoms. A small increase in symptoms (i.e. 20% increase in symptoms) is acceptable. Physical activities that pose no or low risk of sustaining another mTBI/concussion (e.g. walking or stationary cycling) are advisable.
CBR 159
Individuals should be advised to avoid the risk of re-injury (i.e. fall, contact or collision) until a qualified health care professional determines it is safe for higher risk activities. (Children and adults)
EBR (Conditional) 166-168
Explain that transient symptom worsening with increased activity is common.
Practice points for Older people
Where a fall was the cause of mTBI/concussion in an older person (see Glossary), early resumption of daily activities should be encouraged. It is important to provide information on falls prevention strategies.
Further Guidance
Reduced screen use in the first 48 hours after mTBI/concussion is warranted but may not be effective beyond that time.
Practice points for Children
Parents and carers should be aware of general recommendations for screen use in children aged over 5 years; that is,
In light of the limited evidence on pre-hospital tools that specifically determine the need for assessment in the acute hospital setting following mTBI/concussion, the following consensus-based recommendations for adults and children were informed by the Canadian CT Head Rule and the Pediatric Emergency Care Applied Research Network study.43 These are identified as “red flags” in concussion recognition tools. Additional considerations apply for older people (see Glossary) due to the likely presence of comorbidities.
CBR 171-173
People who have experienced mTBI/concussion should be advised to avoid driving or operating heavy machinery during the first 24 hours.
CBR 171-173
People returning to driving should be advised that symptoms such as blurred vision, dizziness, fatigue, impaired cognition, headache and neck pain or stiffness may affect their ability to drive or operate heavy machinery.
Further notes and guidance
Evidence indicates that encouraging people to gradually and progressively (hours and duties) return to some form of meaningful work (paid or unpaid) 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.174
EBR (Conditional) 175-177
Encourage people to return to some form of work, so long as work does not place the person at high risk of reinjury. Facilitate identification of necessary modifications (to decrease the risk of reinjury) and appropriate accommodations by clearly identifying exacerbators of symptoms and functional limitations (physical, cognitive and emotional). (adolescents and adults)
EBR (Conditional) 175-177
Students should have returned to school full-time before commencing extra-curricular work (unless part of educational activity). (adolescents and adults)
CBR 178
When persisting post-concussive symptoms pose a barrier to return to pre-injury employment, introduction of other meaningful activities that facilitate recovery should be considered. Other employment (full-time or part-time), educational activities, community roles, and activities that promote community integration (e.g. volunteer work) may be considered as an alternative focus for meaningful activities. (adults)
Further notes
The transition back to school/university 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.179 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.179
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.180 Educational accommodations should be based on resolution of symptoms (physical, cognitive, emotional and sleep/fatigue) and age/school level of the child/youth.
CBR 178,179,182-184
To minimise academic and social disruptions following mTBI/concussion, qualified health care professionals should not recommend complete rest and isolation, even for the initial 24–48 hours, and instead recommend a period of relative rest. (Children and adults)
CBR 178,179,182-184
Complete absence from the school / education environment for more than one week is not generally recommended. Children/adolescents should receive temporary academic accommodations (e.g. modifications to schedule, classroom environment and workload) to support a return to the school environment in some capacity as soon as possible. (Children and adults)
CBR 178
A child or adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities without overly exacerbating their symptoms, even if they are still experiencing symptoms. Return-to-school protocols should be personalised, gradually increased based on the symptom severity, guided jointly by health-care and school-based teams, and be modified based on ongoing assessment of symptoms. (Children and adolescents)
EBR (Strong) 159,162,163
To minimise academic and social disruptions following mTBI/concussion, qualified health care professionals should not recommend complete rest and isolation, even for the initial 24–48 hours, and instead recommend a period of relative rest. (Children and adults)
CBR 178
A child or adolescent should return to their school environment as soon as they are able to tolerate engaging in cognitive activities without overly exacerbating their symptoms, even if they are still experiencing symptoms. Return-to-school protocols should be personalised, gradually increased based on the symptom severity, guided jointly by health-care and school-based teams, and be modified based on ongoing assessment of symptoms. (Children and adolescents)
CBR 178,179,182-184
Complete absence from the school / education environment for more than one week is not generally recommended. Children/adolescents should receive temporary academic accommodations (e.g. modifications to schedule, classroom environment and workload) to support a return to the school environment in some capacity as soon as possible. (Children and adults)
EBR (Conditional) 179
Return-to-school is a priority in children and adolescents, and while full return to learn is recommended before unrestricted return to sport, the two strategies can occur in parallel. (Children and adolescents)
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 communication and understanding, ideally with a sense of partnership between the school and family.
EBR (Conditional) 187,190-193
For students who experience prolonged symptoms and academic difficulties despite an active treatment approach, qualified health care professionals should refer the child for a formal evaluation by a specialist in paediatric mTBI/concussion, or an interdisciplinary concussion team where available. (Children and adolescents)
Further Guidance
Online information about educational support (right to education) for students for each state or territory is available: Australian Capital Territory, New South Wales, the Northern Territory, Queensland, South Australia, Tasmania, Victoria, and Western Australia.
Deferring return to sport decreases the likelihood of repeat mTBI/concussion.179 Avoidance of repeated head injury decreases time to recovery and decreases length of persisting symptoms.179 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. Returning to sport should occur once the player is symptom free and a minimum time of 21 days from injury.
CBR 32
Return to sport strategies should be individualised, follow the recommended guidelines, and be monitored by a qualified health care professional. (Children and adults)
CBR 178,179,182-184
People who experience mTBI/concussion should gradually progress through return-to-learn and return-to-sport stages ensuring a minimum time away from play of 21 days from injury. (Children and adults)
Further Evidence and Notes