Updated Return-to-Sport Guidelines After Concussion: What Rehab Professionals Need to Know

The most recent systematic review from British Journal of Sports Medicine (Putukian et al., 2023) provides a clearer picture of how we can safely and effectively return athletes to sport following a concussion—without requiring full symptom resolution at the outset.

Here’s what rehab professionals need to know:

🧩 Recovery Timelines at a Glance

• Symptom-free: Mean = 14.0 days

• Return to Sport (RTS): Mean = 19.8 days

These timeframes are longer than in previous decades, reflecting more conservative and evidence-informed management strategies.

🔁 Rethinking the Role of Symptoms in RTS Progression

One of the most critical shifts in concussion management is the recognition that symptoms may still be present during early stages of RTS. Total symptom resolution is no longer required before initiating return-to-sport activities.

This staged approach allows for active rehabilitation and mitigates the drawbacks of prolonged inactivity.

🏃‍♂️ The 6-Stage RTS Framework (with Symptom Considerations)

1. Relative Rest (24–48 hours)

   • Light ADLs and brief cognitive activities are encouraged.

   • Not strict rest—movement and mild stimulation are beneficial.

2. Light Aerobic Exercise

   • Walking, stationary cycling—sub-symptom threshold.

   • Mild, brief symptom exacerbation is acceptable if recovery follows within minutes.

3. Moderate Aerobic + Light Strength Training

   • Advance intensity slightly while monitoring response.

   • Continue to allow mild symptoms, provided they are transient and tolerable.

4. Sport-Specific Activity (No Contact)

   • Agility, cutting, and drills mimicking gameplay without collision.

   • Goal: engage sensorimotor systems while tolerating manageable symptoms.

5. Non-Contact Practice

   • Full team integration with strength and coordination demands.

   • No symptoms at rest and no symptom return during maximal exertion is required from this point forward.

6. Full Contact & Competition

   • Medical clearance required.

   • Athlete should demonstrate symptom-free status with full function under competitive conditions.

💡 Clinical Insights for Rehab Pros

• Mild symptoms are permissible in Stages 1–4 if they do not worsen over time or impair function.

• Emphasize graded exposure to physical and cognitive demands as a therapeutic strategy—not just a test of readiness.

• Delaying activity entirely can be counterproductive; controlled exertion supports neuroplasticity and recovery.

• Psychological readiness and athlete confidence are critical in later stages—don’t neglect this component.

✅ Takeaways for Practice

• The RTS process is no longer symptom elimination before activity, but rather symptom-guided progression.

• Early aerobic activity is a treatment, not just a test.

• Delayed removal from play and waiting too long to initiate care significantly prolong recovery—emphasize early evaluation and education.

• Every concussion is unique—consider pre-existing conditions, prior concussions, and emotional health as you tailor the progression.

Rehab professionals are uniquely positioned to guide athletes through this nuanced, evidence-based recovery journey. Let's shift away from rigid timelines and embrace flexible, patient-centered progression that supports the whole athlete.