 
 
Rehabilitation Protocol for Concussion Return-to-Sport 
  
This protocol is intended to guide clinicians through the return to sport following sports-related concussion.  
 This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be 
based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for 
expected outcomes contained within this guideline may vary based on physician preference, healing timeline and 
sporting activity. Return to sport following concussion can be a complex decision-making process and should be 
approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be 
referred to a concussion specialty clinic.  
  
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician.  
  
Considerations for concussion return to sport 
Current literature no longer supports a period of complete rest beyond 72 hours.  Concussion recovery should be 
focused around active rehabilitation.  Activities should be performed at a sub-symptom threshold to the patient’s 
tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max 
exercise tolerance. If a clinician is not familiar with this testing and exercise prescription, the patient should be referred 
to a specialist. 
  
PHASE I: EARLY POST-INJURY (0-3 DAYS) 
Rehabilitation 
Goals 
• Relative rest 
Precautions 
• Throughout progression, there should be minimal symptoms. If symptoms are  starting, rest see 
if symptoms resolve and the resume at a slightly lower heart rate with goal of not increasing 
symptoms for pre-exercise level 
Intervention 
• Household and community activities as tolerated 
Criteria to 
Progress 
• 3 days post injury 
  
PHASE II: INTERMEDIATE POST-INJURY 
Rehabilitation 
Goals 
• Gradually reintroduce aerobic activity 
• Decrease deconditioning 
Precautions 
• Limit head movement, distractions and maintain neutral neck position 
• Avoid Valsalva 
• No contact 
Additional 
Intervention 
*Continue with 
Phase I 
interventions 
• Light activity to gradually increase heart rate. If symptoms do not increase next session can 
increase workload slightly more 
• Exercise examples: 
• Light biking 
• Walking 
Criteria to 
Progress 
• Tolerating activity well without symptoms, progress through gradually until able to achieve 85% 
of age adjust heart rate without symptoms 
• Able to tolerate daily activities without significant increase in visual/vestibular symptoms 
  
 

PHASE III: LATE POST-INJURY 
Rehabilitation 
Goals 
• Reintroduce movement 
• Progress active rehab 
Precautions 
• Avoid Valsalva 
• No contact 
Additional 
Intervention 
*Continue with 
Phase I-II 
Interventions  
• Increased head movement with activity 
• Running, skating, swimming, rowing, shooting on empty goal, foot work, stick work 
• Increased environmental distractions 
• Busy gym, running with people around 
• Increased cognitive demands 
• Doing math in head, talking, thinking through plays while exercising 
Criteria to 
Progress 
• No symptoms with above exercise 
• Minimal to no symptoms with all activities including daily activities, school, work etc. 
  
PHASE IV: TRANSITIONAL 
Rehabilitation 
Goals 
Reintroduce sport specific activity, while continuing to avoid contact 
Additional 
Intervention 
*Continue with 
Phase I-III 
interventions 
Sport specific activity 
Passing drills, shooting drills, non-contact drill participation 
Criteria to 
Progress 
 No symptoms with above activity 
  
PHASE V: FULL RETURN TO SPORT ( MONTHS AFTER SURGERY) 
Rehabilitation 
Goals 
 Full return to sport 
Additional 
Intervention 
*Continue with 
Phase II-IV 
interventions 
 Scrimmage play first, then full game play if asymptomatic 
 Revised 9/2021 
  
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
References: 
  
1. 
Clausen M et al, Cerebral Blood Flow during Treadmill exercise is a marker of physiological post-concussion syndrome in female athletes. Journal of 
Head Trauma Rehabilitation 2016 31 (3): 215-24.  
2. 
Coslick, A, et al. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to 
Recovery. PM&R,; 2020 (12)12: 1195–1204.  
3. 
DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged Activity Restriction after Concussion: Are We 
Worsening Outcomes? Clinical Pediatrics, 55(5), 443–451.  
4. 
 Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent 
Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504. doi:10.1001/jama.2016.17396 
5. 
 Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 
2017;51(12):935-940. doi:10.1136/bjsports-2016-097464 
6. 
Leddy JJ et al. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12 (6): 370-376, 
2013. 
7. 
 Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. 
doi:10.1249/JSR.0000000000000505 
8. 
 Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management. Curr Sports Med Rep. 2013;12(6):370-376. 
doi:10.1249/JSR.0000000000000008 
9. 
Muruta J et al. Visual Tracking synchronization as a metric for concussion screening. J Head Trauma Rehabil 2010 Jul-Aug; 25 (4):293-305. 
10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. 
Pediatrics. 2015;135(2). 
