Return to sport
Graduated return to sport

The process of recovery and then return to sport participation after an SRC follows a graduated stepwise rehabilitation strategy, an example of which is outlined in table 1. This table has been modified from previous versions to improve clarity.

Table oneTable Two

Treatment of Concussions

The treatment of the concussed patient will potentially involve many different physicians and other healthcare providers. Up until the past 10 years or so…..

For this reason, it is important to realize that any head injury is a potential serious injury which needs to be watched and monitored by a person close to the injured patient who can alert the patient and healthcare professionals of how the patient may not be acting as his or her normal self, and to seek appropriate evaluation.


In the broadest clinical sense, Sports Related Concussion is often defined as representing the immediate and transient symptoms of traumatic brain injury (TBI). Such operational definitions, however, do not give any insights into the underlying processes through which the brain is impaired, nor do they distinguish different grades of severity, nor reflect newer insights into the persistence of symptoms and/or abnormalities on specific investigational modalities. This issue is clouded not only by the lack of data, but also by confusion in definition and terminology. Often the term mild traumatic brain injury (mTBI) is used interchangeably with concussion; however, this term is similarly vague and not based on validated criteria in this context.
One key unresolved issue is whether concussion is part of a TBI spectrum associated with lesser degrees of diffuse structural change than are seen in severe TBI, or whether the concussive injury is the result of reversible physiological changes. The term concussion, while useful, is imprecise, and because disparate author groups define the term differently, comparison between studies is problematic. In spite of these problems, the CISG has provided a consistent definition of SRC since 2000.1
The Berlin expert panel modified the previous CISG definition as follows:
Sport related concussion is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilised in clinically defining the nature of a concussive head injury include:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
    SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
    SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
    SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged

The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc) or other comorbidities (eg, psychological factors or coexisting medical conditions).

Do the published biomechanical studies inform us about the definition of SRC?

Many studies have reported head-impact-exposure patterns for specific sports—for example, American football, ice hockey and Australian football. Those studies report head-impact characteristics including frequency, head kinematics, head-impact location, and injury outcome. In these studies, the use of instrumented helmets has provided information on head-impact exposures, although there remains some debate about the accuracy and precision of the head kinematic measurements. To quantify head impacts, studies have used helmet-based systems, mouth guard/headband/skin sensors and video metric studies; however, reported mean peak linear and rotational acceleration values in concussed players vary considerably.
Although current helmet-based measurement devices may provide useful information for collision sports, these systems do not yet provide data for other (non-collision) sports, limiting the value of this approach. Furthermore, accelerations detected by a sensor or video-based systems do not necessarily reflect the impact to the brain itself, and values identified vary considerably between studies. The use of helmet-based or other sensor systems to clinically diagnose or assess SRC cannot be supported at this time.

Sideline evaluation

Many studies have reported head-impact-exposure patterns for specific sports—for example, American football, ice hockey and Australian football. Those It is important to note that SRC is an evolving injury in the acute phase, with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. SRC is considered to be among the most complex injuries in sports medicine to diagnose, assess and manage. The majority of SRCs occur without loss of consciousness or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of SRC in the sporting environment. Because of this evolving process, it is not possible to rule out SRC when an injury event occurs associated with a transient neurological symptom. In all suspected cases of concussion, the individual should be removed from the playing field and assessed by a physician or licensed healthcare provider as discussed below.
Sideline evaluation of cognitive function is an essential component in the assessment of this injury. Brief neuropsychological (NP) test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the SCAT5, which incorporates the Maddocks’ questions6 7 and the Standardised Assessment of Concussion (SAC).8–10 It is worth noting that standard orientation questions (eg, time, place, person) are unreliable in the sporting situation when compared with memory assessment.7 11 It is recognised, however, that abbreviated testing paradigms are designed for rapid SRC screening on the sidelines and are not meant to replace a comprehensive neurological evaluation; nor should they be used as a standalone tool for the ongoing management of SRC.
A key concept in sideline assessment is the rapid screening for a suspected SRC, rather than the definitive diagnosis of head injury. Players manifesting clear on-field signs of SRC (eg, loss of consciousness, tonic posturing, balance disturbance) should immediately be removed from sporting participation. Players with a suspected SRC following a significant head impact or with symptoms can proceed to sideline screening using appropriate assessment tools—for example, SCAT5. Both groups can then proceed to a more thorough diagnostic evaluation, which should be performed in a distraction-free environment (eg, locker room, medical room) rather than on the sideline.
In cases where the physician may have been concerned about a possible concussion, but after the sideline assessment (including additional information from the athlete, the assessment itself and/or inspection of videotape of the incident) concussion is no longer suspected, then the physician can determine the disposition and timing of return to play for that athlete.
We acknowledge that many contact sports are played at a fast pace in a disorganised environment, where the view of on-field incidents is often obscured and the symptoms of SRC are diverse, all of which adds to the challenge of the medical assessment of suspected SRC. Furthermore, evolving and delayed-onset symptoms of SRC are well documented and highlight the need to consider follow-up serial evaluation after a suspected SRC regardless of a negative sideline screening test or normal early evaluation.
The recognition of suspected SRC is therefore best approached using multidimensional testing guided via expert consensus. The SCAT5 currently represents the most well-established and rigorously developed instrument available for sideline assessment. There is published support for using the SCAT and Child SCAT in the evaluation of SRC. The SCAT is useful immediately after injury in differentiating concussed from non-concussed athletes, but its utility appears to decrease significantly 3–5 days after injury. The symptom checklist, however, does demonstrate clinical utility in tracking recovery. Baseline testing may be useful, but is not necessary for interpreting post-injury scores. If used, clinicians must strive to replicate baseline testing conditions. Additional domains that may add to the clinical utility of the SCAT tool include clinical reaction time, gait/balance assessment, video-observable signs and oculomotor screening.
The addition of sideline video review offers a promising approach to improving identification and evaluation of significant head-impact events, and a serial SRC evaluation process appears to be important to detect delayed-onset SRC. Other tools show promise as sideline screening tests but require adequately powered diagnostic accuracy studies that enrol a representative sample of athletes with suspected SRC. Collaboration between sporting codes to rationalise multimodal diagnostic sideline protocols may help facilitate more efficient application and monitoring. Current evidence does not support the use of impact sensor systems for real-time SRC screening.

Symptoms and signs of acute SRC

Recognising and evaluating SRC in the adult athlete on the field is a challenging responsibility for the healthcare provider. Performing this task often involves a rapid assessment in the midst of competition with a time constraint and the athlete eager to play. A standardised objective assessment of injury that excludes more serious injury is critical in determining disposition decisions for the athlete. The sideline evaluation is based on recognition of injury, assessment of symptoms, cognitive and cranial nerve function, and balance. Serial assessments are often necessary. Because SRC is often an evolving injury, and signs and symptoms may be delayed, erring on the side of caution (ie, keeping an athlete out of participation when there is any suspicion of injury) is important.
The diagnosis of acute SRC involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioral features and sleep/wake disturbance. Furthermore, a detailed concussion history is an important part of the evaluation both in the injured athlete and when conducting a pre-participation examination.
The suspected diagnosis of SRC can include one or more of the following clinical domains:

  • Symptoms: somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability)
    Physical signs (eg, loss of consciousness, amnesia, neurological deficit)
    Balance impairment (eg, gait unsteadiness)
    Behavioural changes (eg, irritability)
    Cognitive impairment (eg, slowed reaction times)
    Sleep/wake disturbance (eg, somnolence, drowsiness)

If symptoms or signs in any one or more of the clinical domains are present, an SRC should be suspected and the appropriate management strategy instituted. It is important to note, however, that these symptoms and signs also happen to be non-specific to concussion, so their presence simply prompts the inclusion of concussion in a differential diagnosis for further evaluation, but the symptom is not itself diagnostic of concussion.


When a player shows any symptoms or signs of an SRC:

  • The player should be evaluated by a physician or other licensed healthcare provider on site using standard emergency management principles, and particular attention should be given to excluding a cervical spine injury.
    The appropriate disposition of the player must be determined by the treating healthcare provider in a timely manner. If no healthcare provider is available, the player should be safely removed from practice or play and urgent referral to a physician arranged.
    Once the first aid issues are addressed, an assessment of the concussive injury should be made using the SCAT5 or other sideline assessment tools.
    The player should not be left alone after the injury, and serial monitoring for deterioration is essential over the initial few hours after injury.
    A player with diagnosed SRC should not be allowed to return to play on the day of injury.

sporting environment and a multimodal assessment should be conducted in a standardized fashion (eg, the SCAT5). Sporting bodies should allow adequate time to conduct this evaluation. For example, completing the SCAT alone typically takes 10 min. Adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes. In some sports, this may require rule changes to allow an appropriate off-field medical assessment to occur without affecting the flow of the game or unduly penalizing the injured player’s team. The final determination regarding SRC diagnosis and/or fitness to play is a medical decision based on clinical judgement.


An athlete with SRC may be evaluated in the emergency room or doctor’s office as a point of first contact after injury or may have been referred from another care provider. In addition to the points outlined above, the key features of follow-up examination should encompass:

  • A medical assessment including a comprehensive history and detailed neurological examination including a thorough assessment of mental status, cognitive functioning, sleep/wake disturbance, ocular function, vestibular function, gait and balance.
    Determination of the clinical status of the patient, including whether there has been improvement or deterioration since the time of injury. This may involve seeking additional information from parents, coaches, teammates and eyewitnesses to the injury.
    Determination of the need for emergent neuroimaging to exclude a more severe brain injury (eg, structural abnormality).

Neuropsychological assessment

Neuropsychological assessment (NP) has been previously described by the CISG as a ‘cornerstone’ of SRC management. Neuropsychologists are uniquely qualified to interpret NP tests and can play an important role within the context of a multifaceted—multimodal and multidisciplinary approach to managing SRC. SRC management programmes that use NP assessment to assist in clinical decision-making have been instituted in professional sports, colleges and high schools.
The application of NP testing in SRC has clinical value and contributes significant information in SRC evaluation.12–17 Although in most cases, cognitive recovery largely overlaps with the time course of symptom recovery, cognitive recovery may occasionally precede or lag behind clinical symptom resolution, suggesting that the assessment of cognitive function should be an important component in the overall assessment of SRC and, in particular, any return-to-play protocol.18 19 It must be emphasized, however, that NP assessment should not be the sole basis of management decisions. Rather, it provides an aid to the clinical decision-making process in conjunction with a range of assessments of different clinical domains and investigational results.
It is recommended that all athletes should have a clinical neurological assessment (including evaluation of mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function and balance) as part of their overall management. This will normally be performed by the treating physician, often in conjunction with computerized NP screening tools.
Brief computerized cognitive evaluation tools are a commonly utilized component of these assessments worldwide given the logistical limitation in accessing trained neuropsychologists. However, it should be noted that these are not substitutes for complete NP assessment.
Baseline or pre-season NP testing was considered by the panel and was not felt to be required as a mandatory aspect of every assessment; however, it may be helpful or add useful information to the overall interpretation of these tests. It also provides an additional educative opportunity for the healthcare provider to discuss the significance of this injury with the athlete.
Post-injury NP testing is not required for all athletes. However, when this is considered necessary, the assessment should optimally be performed by a trained and accredited neuropsychologist. Although neuropsychologists are in the best position to interpret NP tests by virtue of their background and training, the ultimate return-to-play decision should remain a medical one in which a multidisciplinary approach, when possible, has been taken. In the absence of NP and other testing, a more conservative return-to-play approach may be appropriate.
Post-injury NP testing may be used to assist return-to-play decisions and is typically performed when an athlete is clinically asymptomatic. However, NP assessment may add important information in the early stages after injury.20 21 There may be particular situations where testing is performed early to assist in determining aspects of management—for example, return to school in a paediatric athlete. This will normally be best determined in consultation with a trained neuropsychologist.22 23

Concussion investigations

Over the past decade, we have observed major progress in clinical methods for evaluation of SRC and in determining the natural history of clinical recovery after injury. Critical questions remain, however, about the acute neurobiological effects of SRC on brain structure and function, and the eventual time course of physiological recovery after injury. Studies using advanced neuroimaging techniques have demonstrated that SRC is associated with changes in brain structure and function, which correlate with post-concussive symptoms and performance in neurocognitive testing during the acute post-injury phase.
The assessment of novel and selective fluid (eg, blood, saliva and cerebrospinal fluid) biomarkers and genetic testing for TBI has rapidly expanded in parallel with imaging advances, but this currently has limited application to the clinical management of SRC. Extending from the broader TBI literature, there is also increasing interest in the role of genetics in predicting risk of (i) initial injury, (ii) prolonged recovery and long-term neurological health problems associated with SRC, and (iii) repetitive head-impact exposure in athletes.
Clinically, there is a need for diagnostic biomarkers as a more objective means to assess the presence/severity of SRC in athletes. Beyond the potential diagnostic utility, there is also keen interest in the development of prognostic biomarkers of recovery after SRC. Imaging and fluid biomarkers that reliably reflect the extent of neuronal, axonal and glial damage and/or microscopic pathology could conceivably diagnose and predict clinical recovery outcome and/or determine risk of potential cumulative impairments after SRC.
Advanced neuroimaging, fluid biomarkers and genetic testing are important research tools, but require further validation to determine their ultimate clinical utility in evaluation of SRC.


Most consensus and agreement statements for managing SRC recommend that athletes rest until they become symptom-free. Accordingly, prescribed rest is one of the most widely used interventions in this population. The basis for recommending physical and cognitive rest is that rest may ease discomfort during the acute recovery period by mitigating post-concussion symptoms and/or that rest may promote recovery by minimising brain energy demands following concussion.
There is currently insufficient evidence that prescribing complete rest achieves these objectives. After a brief period of rest during the acute phase (24–48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms). It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study.


This summary statement regarding the potential for concussion rehabilitation must be read in conjunction with the systematic review paper, which details the background, search strategy, citations and reasoning for this statement. As ‘Rehabilitation’ did not exist as a separate section in the previous Consensus Statements, this section is all in italics.
SRCs can result in diverse symptoms and problems, and can be associated with concurrent injury to the cervical spine and peripheral vestibular system. The literature has not evaluated early interventions, as most individuals recover in 10–14 days. A variety of treatments may be required for ongoing or persistent symptoms and impairments following injury. The data support interventions including psychological, cervical and vestibular rehabilitation.
In addition, closely monitored active rehabilitation programmes involving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery. A collaborative approach to treatment, including controlled cognitive stress, pharmacological treatment, and school accommodations, may be beneficial.
Further research evaluating rest and active treatments should be performed using high-quality designs that account for potential confounding factors, and have matched controls and effect modifiers to best inform clinical practice and facilitate recovery after SRC.

Refer Persistent symptoms

A standard definition for persistent post-concussive symptoms is needed to ensure consistency in clinical management and research outcomes. The Berlin expert consensus is that use of the term ‘persistent symptoms’ following SRC should reflect failure of normal clinical recovery—that is, symptoms that persist beyond expected time frames (ie, >10–14 days in adults and >4 weeks in children).
‘Persistent symptoms’ does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain. A detailed multimodal clinical assessment is required to identify specific primary and secondary pathologies that may be contributing to persisting post-traumatic symptoms. At a minimum, the assessment should include a comprehensive history, focused physical examination, and special tests where indicated (eg, graded aerobic exercise test). Currently, while there is insufficient evidence for investigations, such as EEG, advanced neuroimaging techniques, genetic testing and biomarkers, to recommend a role in the clinical setting, their use in the research setting is encouraged.
Treatment should be individualised and target-specific medical, physical and psychosocial factors identified on assessment. There is preliminary evidence supporting the use of:

  • an individualised symptom-limited aerobic exercise programme in patients with persistent post-concussive symptoms associated with autonomic instability or physical deconditioning, and
    a targeted physical therapy programme in patients with cervical spine or vestibular dysfunction, and
    a collaborative approach including cognitive behavioural therapy to deal with any persistent mood or behavioural issues.

Currently, there is limited evidence to support the use of pharmacotherapy. If pharmacotherapy is used, then an important consideration in return to sport is that concussed athletes should not only be free from concussion-related symptoms, but also should not be taking any pharmacological agents/medications that may mask or modify the symptoms of SRC. Where pharmacological therapy may be begun during the management of an SRC, the decision to return to play while still on such medication must be considered carefully by the treating clinician.
Overall, these are difficult cases that should be managed in a multidisciplinary collaborative setting, by healthcare providers with experience in SRC.


There is tremendous interest in identifying factors that might influence or modify outcome from SRC. Clinical recovery is defined functionally as a return to normal activities, including school, work and sport, after injury. Operationally, it encompasses a resolution of post-concussion-related symptoms and a return to clinically normal balance and cognitive functioning.
It is well established that SRCs can have large adverse effects on cognitive functioning and balance in the first 24–72 hours after injury. Injured athletes report diverse physical, cognitive and emotional symptoms during the initial days after injury, and a greater number and severity of symptoms after an SRC predict a slower recovery in some studies.
For most injured athletes, cognitive deficits, balance and symptoms improve rapidly during the first 2 weeks after injury. Many past studies, particularly those published before 2005, concluded that most athletes recover from SRC and return to sport within 10 days. This is generally true, but that conclusion should be tempered by the fact that many studies reported group-level findings only, not clinical outcomes from individual athletes, and group statistical analyses can obscure subgroup results and individual differences. There is also historical evidence that some athletes returned to play while still symptomatic, well before they were clinically recovered. Moreover, during the past 10 years, there has been a steadily accumulating literature that a sizeable minority of youth, high-school and collegiate athletes take much longer than 10 days to clinically recover and return to sport.
Some authors have suggested that the longer recovery times reported in more recent studies partially reflects changes in the medical management of SRC, with adoption of the gradual return-to-play recommendations from the CISG statements. This seems likely because these return-to-play recommendations include no same-day return to play and a sequential progression through a series of steps before medical clearance for return to sport. Longer recovery times reported by some studies are also significantly influenced by ascertainment bias—that is, studies that rely, or report data, on clinical samples have a major selection bias and will report longer recovery times than those reported from truly incident cohort studies that provide a more accurate estimate of recovery time.
At present, it is reasonable to conclude that the large majority of injured athletes recover, from a clinical perspective, within the first month of injury. Neurobiological recovery might extend beyond clinical recovery in some athletes. Clinicians know that some student athletes report persistent symptoms for many months after injury, that there can be multiple causes for those symptoms, and that those individuals are more likely to be included in studies conducted at specialty clinics. There is a growing body of literature indicating that psychological factors play a significant role in symptom recovery and contribute to risk of persistent symptoms in some cases.
Researchers have investigated whether pre-injury individual differences, initial injury severity indicators, acute clinical effects, or subacute clinical effects or comorbidities influence outcome after SRC. Numerous studies have examined whether genetics, sex differences, younger age, neurodevelopmental factors such as attention deficit hyperactivity disorder or learning disability, personal or family history of migraine, or a personal or family history of mental health problems are predictors or effect modifiers of clinical recovery from SRC. Having a past SRC is a risk factor for having a future SRC, and having multiple past SRCs is associated with having more physical, cognitive and emotional symptoms before participation in a sporting season. Therefore, it is not surprising that researchers have studied whether having prior SRCs is associated with slower recovery from an athlete’s next SRC. There have been inconsistent findings regarding whether specific injury severity characteristics, such as loss of consciousness, retrograde amnesia, or post-traumatic amnesia, are associated with greater acute effects or prolonged recovery. Numerous post-injury clinical factors, such as the initial severity of cognitive deficits, the development of post-traumatic headaches or migraines, experiencing dizziness, difficulties with oculomotor functioning, and experiencing symptoms of depression have all been associated with worse outcomes in some studies.
The strongest and most consistent predictor of slower recovery from SRC is the severity of a person’s initial symptoms in the first day, or initial few days, after injury. Conversely, and importantly, having a low level of symptoms in the first day after injury is a favourable prognostic indicator. The development of subacute problems with migraine headaches or depression are likely risk factors for persistent symptoms lasting more than a month. Children, adolescents and young adults with a pre-injury history of mental health problems or migraine headaches appear to be at somewhat greater risk of having symptoms for more than 1 month. Those with attention deficit hyperactivity disorder or learning disabilities might require more careful planning and intervention regarding returning to school, but they do not appear to be at substantially greater risk of persistent symptoms beyond a month. Very little research to date has been carried out on children under the age of 13. There is some evidence that the teenage years, particularly the high-school years, might be the most vulnerable time period for having persistent symptoms—with greater risk for girls than boys.

Establishing time of recovery for SRC

Establishing the time of recovery after an SRC is a difficult task for healthcare providers. These determinations have been limited by lack of a gold standard as well as subjective symptom scores and imperfect clinical and NP testing. In addition, patients frequently experience more persistent symptoms, including, but not limited to, chronic migraines, anxiety, post-traumatic stress disorder (PTSD), attention problems and sleep dysfunction. Clinicians must determine whether these are premorbid maladies, downstream effects of SRC, or unrelated challenges while being mindful of the potential for repeat injuries when returning patients to sport too early. Providers are often left in a quandary with limited data to make decisions. Moreover, recent literature suggests that the physiological time of recovery may outlast the time for clinical recovery. The consequence of this is as yet unknown, but one possibility is that athletes may be exposed to additional risk by returning to play while there is ongoing brain dysfunction.
In a research context, modalities that measure physiological change after SRC can be categorised into the following:

  • functional MRI (fMRI)
    diffusion tensor imaging (DTI)
    magnetic resonance spectroscopy (MRS)
    cerebral blood flow (CBF)
    heart rate
    measure of exercise performance
    fluid biomarkers
    transcranial magnetic stimulation (TMS).

Owing to differences in modalities, time course, study design and outcomes, it is not possible to define a single ‘physiological time window’ for SRC recovery. Multiple studies suggest that physiological dysfunction may outlast current clinical measures of recovery, supporting a ‘buffer zone’ of gradually increasing activity before full contact risk. Future studies need to use generalisable populations, longitudinal designs following to physiological and clinical recovery, and careful correlation of neurobiological modalities with clinical measures. At this stage, these modalities, while useful as research tools, are not ready for clinical management.