Guidelines for Recovery

Concussion Alliance has created a framework of guidelines for recovery from a concussion. This framework is based on the 6th international consensus on concussion in sport. Even if you did not get your concussion from sports, these guidelines are important as they reflect the international consensus on the best way to manage a concussion.

Contents

Evaluation, remove from sport or further harm, professional medical evaluation

The first 24-48 hours: don't cocoon, walking, reduce screen time

What to take in the first 48 hours (medication)

Other Do’s and Don’ts Early in Recovery

Exercise After 48 hours

Limit screen time in the first 7–10 days

Request referral for early care for some symptoms

Seek care for persisting symptoms

Information about medication

Vision therapy

Additional therapies

Click on the image above of the Concussion Recognition Tool for the pdf of the CRT6, which is "to be “used by non-medically trained individuals for the identification and management of a suspected concussion,”

Click on the image below for the Concussion Pathway by CATT, which is a flow chart of how to manage a concussion.

• A concussion patient does not need to be woken up every hour at night. Allow a concussion patient to sleep through the night.

• Do not drive, ride your bike, use heavy machinery, or climb ladders until cleared by a healthcare provider. Reaction time, vision, and thinking may be affected by a concussion.

• “Don't do activities with risk of falls or re-injury, play sports, do heavy chores or activities that could lead to another concussion or cause symptoms to worsen.”

• Prioritize your mental well-being. Stay connected with friends–for instance, with a phone call.

• Manage your energy; see this guide, How to Manage Your Energy After A Concussion.

Start with mild-intensity exercise and gradually progress to moderate-intensity exercise

Guidelines now recommend starting exercise after 24-48 hours as tolerated and suggest “walking or stationary cycling while avoiding the risk of contact, collision or fall.” If you can work with a physical therapist to help you tailor your return to exercise based on an exercise test that measures your heart rate, that is ideal.

Do light-intensity physical activity such as 15-30 minute walks or riding an upright or recumbent stationary bicycle. Use caution if you have symptoms like dizziness or light-headedness, which may increase your risk of falling; a stationary bike is the safest option in this case. 

How to judge if you are doing mild-intensity exercise

It is OK if this light-intensity physical activity worsens symptoms only a little bit and if, within an hour of exercising, symptom levels go back to where they were before exercising. 

Specifically, when exercising, your symptoms should not worsen more than 1-2 points on a 10-point scale (based on your impression of symptoms) compared to how symptoms were before exercising.

Physical activity should be stopped if light-intensity physical activity increases symptoms more than a little bit (more than 2 points). Physical activity should also be stopped if worsened symptoms last more than one hour after stopping the physical activity. Physical activity “may be resumed once symptoms have returned to the prior level.”

See our resource Graduated Exercise Therapy for more information about this process.

How to progress to moderate-level exercise

You can slowly progress your exercising. According to the latest guidelines, “Individuals can systematically advance their exercise intensity based on the degree of symptom exacerbation experienced during the prior bout of aerobic exercise.” We have more details in our Graduated Exercise Therapy resource.

Keep in mind that overly strenuous exercise can “exacerbate symptoms, decrease neurocognitive performance, and increase the risk of secondary injury.”

Suggested resources on exercise

We have a resource, Graduated Exercise Therapy, which describes how to create an individualized subsymptom threshold aerobic exercise program; it includes working with a PT to help create your individualized program and an option on how to create a program on your own.

Additional information can be found in our blog post Aerobic Exercise as Therapy.

Another option is to refer to the stage-by-stage description of a gradual Return to Sport (or Activity) in this flyer from the Concussion Awareness Training Tool. Note that the first stage is described as physical and cognitive rest for the first few days–this advice has been updated in 2023 to recommend “relative rest,” see above.

The science behind early return to exercise

Aerobic exercise that is just below the level of making symptoms worse (the subsymptom threshold) “safely speeds recovery” and reduces symptoms in those with persistent post-concussion symptoms. Another study found that twenty minutes of daily subsymptom threshold aerobic exercise speeds recovery in adolescent athletes.

A review of multiple studies found that an individualized program starting with mild aerobic exercise and gradually building to moderate aerobic exercise, either on a stationary bicycle, treadmill, walking, or swimming, had the most effective outcomes.

Note that the term “subsymptom threshold” is a bit of a misnomer; the goal is exercise “that does not elicit more than mild symptom exacerbation.” You should stop exercising when you experience “an increase of more than two points on a 0–10 point scale” compared to your pre-exercise, resting symptom value on the 10-point scale.

Dizziness, neck pain, headaches

If dizziness, neck pain and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended.” Cervicovestibular rehabilitation is physical therapy for the neck (cervical) and the vestibular system. See our resources on Physical Therapy and Vestibular Therapy for more information.

Although not mentioned in the guidelines, it can take time to get in to see a physical therapist. Therefore, if you are experiencing persisting dizziness, neck pain, and/or headaches, it may make sense to request a referral to a physical therapist with cervicovestibular experience as soon as possible or during your first doctor’s visit since referrals take time to process. Read more about this on our Physical Therapy resource.

Mental health issues

Recommendations for physicians caring for children and adolescents include this advice:
”Consider early referral (< 4 weeks) if child/adolescent has modifiers that may delay recovery/high risk of prolonged post-concussion symptoms.” The modifiers, or complicating factors, include previous “mental illness, family history of mental illness, migraine, current stress level, and any other modifiers that may delay recovery.”