Concussion Management: Recovery Protocols from the International Consensus Statement on Concussion in Sport

Introduction: A New Era in Concussion Care

A concussion is considered a mild traumatic brain injury that typically causes temporary dysfunction, yet leaves individuals vulnerable during recovery. While most concussions resolve within 5-7 days, the brain's energy deficit takes 22-30 days to fully restore - explaining why current guidelines recommend a 3-week return-to-sport period.

The latest international consensus, developed by the Concussion in Sport Group, represents a paradigm shift in how healthcare professionals assess and manage concussion recovery, with physiotherapy taking a central role in facilitating safe return to activity.

Key Changes in Concussion Diagnosis: New Tools and Criteria

The Amsterdam consensus introduces updated assessment tools and a refined conceptual definition of sport-related concussion (SRC). These developments help clinicians make more accurate diagnoses and better monitor recovery progression.

Updated Diagnostic Tools

The consensus introduces revised assessment tools that are more sensitive and comprehensive than previous versions:

• Concussion Recognition Tool 6 (CRT6): Designed for non-medical personnel to identify potential concussions
• Sport Concussion Assessment Tool 6 (SCAT6) and Child SCAT6: For healthcare professionals to evaluate athletes aged 13+ and 8-12 respectively
• Sport Concussion Office Assessment Tool 6 (SCOAT6) and Child SCOAT6: For subacute evaluation (72+ hours post-injury) to guide treatment planning

These tools incorporate more challenging cognitive tests, including longer word lists and enhanced digit span tasks to reduce ceiling effects, along with timed dual-task gait assessment and measures of orthostatic vital signs to identify autonomic nervous system dysfunction.

Refined Concussion Definition

The consensus panel updated the conceptual definition of sport-related concussion to reflect current understanding of the underlying pathophysiology:

The Active Recovery Paradigm: Moving Beyond "Cocoon Therapy"

One of the most significant shifts in the new consensus is the move away from strict rest toward active rehabilitation, fundamentally changing how physiotherapists approach concussion management in the critical first days and weeks.

Early Active Rehabilitation

The consensus clearly states that prolonged strict rest (often called "cocoon therapy") is not beneficial for recovery. Instead, the recommendations now emphasize:

• Relative rest for the first 24-48 hours only
• Gradual return to light activities of daily living after 48 hours
• Light-intensity physical activity such as walking or stationary cycling that doesn't significantly exacerbate symptoms
• Progressive increase of both cognitive and physical activities based on symptom tolerance

Research shows that prescribed sub-symptom threshold aerobic exercise (exercise performed at a level that doesn't significantly worsen symptoms) can be safely implemented within 2-10 days after concussion and is effective for reducing the incidence of persistent symptoms.

Understanding Exercise Intolerance

Concussion often results in exercise intolerance - the inability to perform physical activity without exacerbating symptoms. This appears linked to autonomic nervous system dysfunction and impaired regulation of cerebral blood flow during exercise.

Physiotherapists can assess this using controlled exercise testing (such as the Buffalo Concussion Treadmill Test) to establish safe exercise thresholds and prescribe individualised rehabilitation programs.

The Graduated Return-to-Sport Protocol: A Stepwise Approach

The consensus provides a clear, six-step strategy for returning athletes to sport, emphasising that progression should be guided by symptoms and clinical findings rather than a predetermined timeline.

Each step should typically take a minimum of 24 hours, with most athletes completing the protocol in about one month post-concussion. Athletes must remain symptom-free at each stage before progressing and should return to Step 1 if symptoms reappear.

Physiotherapy Interventions for Concussion Recovery

Physiotherapists employ various evidence-based techniques to address specific concussion symptoms and facilitate recovery, particularly for patients with persistent symptoms.

Cervicovestibular Rehabilitation

Neck injuries frequently accompany concussions, and cervicogenic symptoms can contribute to headaches, dizziness, and balance problems. The consensus recommends:

• Cervicovestibular rehabilitation for dizziness, neck pain, and/or headaches persisting beyond 10 days
• Manual therapy techniques addressing joint dysfunction and muscle tension
• Targeted exercises for oculomotor function, balance, and vestibular adaptation

Subsymptom Threshold Aerobic Exercise

Based on strong evidence, physiotherapists now prescribe individualized sub-symptom threshold exercise programs to restore autonomic nervous system function and improve exercise tolerance:

• Exercise prescription based on heart rate thresholds established during exercise testing
• Progressive increase in intensity and duration as tolerance improves
• Systematic progression guided by repeat testing every few days to weekly

Multiple studies demonstrate that this approach normalises CO2 sensitivity, improves regulation of cerebral blood flow, and restores exercise tolerance in patients with persistent post-concussion symptoms.

Special Considerations for Different Populations

The consensus highlights important modifications to concussion management for specific populations, recognising that a one-size-fits-all approach is inadequate.

Children and Adolescents

Young athletes require special considerations:

• Longer recovery periods may be needed
• Return-to-learn must precede return-to-sport
• Academic accommodations may be necessary during recovery
• Modified assessment tools (Child SCAT6 and Child SCOAT6) account for developmental differences

Para Athletes

The 2022 consensus marks the first inclusion of para athlete considerations in international concussion guidelines. Management must account for:

• Pre-existing impairments that may affect concussion presentation and assessment
• Modified testing protocols (e.g., arm ergometry instead of treadmill testing for wheelchair users)
• Sport-specific risks in adaptive sports
• Individualised baseline testing where possible

Multidisciplinary Management: The Team Approach

While physiotherapists play a crucial role in concussion management, the consensus emphasises that complex cases often require multidisciplinary care. Physiotherapists may collaborate with:

• Physicians for medical clearance and medication management
• Neuropsychologists for cognitive assessment and intervention
• Vestibular therapists for specialised balance rehabilitation
• Occupational therapists for return-to-learn and activities of daily living
• Optometrists for vision therapy when needed

This team approach is particularly important for patients with persisting symptoms (lasting >4 weeks), who benefit from comprehensive, coordinated care addressing all aspects of their presentation.