Individualised Rehabilitation return to Sport Process

The goal of the early management of concussion is to settle symptoms and return to normal activities of daily living (which do not provoke symptoms) as soon as possible. Research now shows that prolonged periods of inactivity are not helpful. Rest is now best described as ‘relative rest’.

• Rest after a diagnosed concussion and within 48 hours of the injury means normal activities of daily living which do not significantly worsen symptoms. Vigorous activity should be avoided. Relative cognitive rest, limiting screen time etc.-ensure minimal exacerbation of symptoms.
• After the initial 48 hours the resumption of activity including exercise is encouraged and defined as “activity below the level at which physical activity or cognitive activity significantly provokes symptoms” 

The individualised rehabilitation process should aim to  move the player through gradually increasing exercise intensity, ensuring it is tolerated. As with all rehabilitation processes there is no one correct way to complete. A risk stratification should be included:

• The players previous concussion history
• Their acute presentation
• Their symptom and cognitive burden at the time of diagnosing concussion

In the community game there is a minimum stand down from playing for a minimum of 21 days, with the date of injury being day 0.  Individual unions will have developed their strategies and advice. An example is players miss a minimum of two weeks with the potential to play on the third weekend. If symptom free, they will be able to start non-contact training activities in the second week with resistance training activities also started in this week. 

Training activities with a predictable risk of head injury can then be introduced in week 3 (but only if/when the player has been symptom free for 14 days). The return to sport progression can occur at a rate that does not, more than mildly, exacerbate existing symptoms or produce new symptoms.

Below is an example of a return-to-sport process published following the Amsterdam 2022 International Consensus Statement on Concussion in Sport. This highlights a staged approach to increasing activity and also advises on managing possible mild symptom exacerbation during exercise phases.

In this example steps 1-3 are exercise-based treatments which are part of recovery from concussion and during which the player may still have mild symptoms; stages 4-6 are graduated return to rugby-related activities for which the player should have returned to a baseline symptom score. Progression through each step typically takes a minimum of 24 hours. 

Players may commence light aerobic exercise (up to 55% max heart rate) and if tolerated moderate aerobic exercise (up to 70% mas heart rate) at stage 2. A mild and brief exacerbation (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) resolving within an hour is acceptable after activity. If more than mild exacerbation of symptoms occurs during steps 1-3, the athlete should stop and attempt to exercise the next day.

In rugby training steps 4-6 run the risk of head impacts so progression to stages should happen only when the player has fully returned to baseline for symptoms, cognitive function and those caring for the player are satisfied the player is normalising.

If a player experiences concussion-related symptoms during Steps 4-6, they should return to Step 3 to establish full resolution of symptoms with exertion before engaging in at-risk activities.

The player's rehabilitation is personalised based on their history, presentation and the risk stratification process. In the same manner any symptoms at the time of sustaining the concussion should be included in the individualised rehabilitation process. Examples of this include:

• Rehabilitation for symptoms of balance disturbance, blurred vision or dizziness.
• Cervical spine rehabilitation for neck pain
• Psychological assessment and intervention where a player endorses ongoing anxiety, irritability or sadness.

Delayed recovery and persisting concussion symptoms:

Players who have difficulty progressing through individulised rehabilitation who have signs or symptoms that are not progressively improving, beyond the first 2-4 weeks may benefit from targeted rehabilitation and further specialist consultation.