Treating concussion one step at a time

After a concussion, the first questions often concern rest, returning to school or work, and resuming sports. A recovery plan tailored to the symptoms helps organize each stage of recovery.

Most people recover within a few weeks, often within the first month. Appropriate endurance exercise, such as walking or using a stationary bike, can be part of the treatment.^{1, 2} Symptoms are considered persistent when they last longer than four weeks. Recovery occurs in stages, without prolonged complete rest or a hasty return to high-risk activities.

• Complete and prolonged rest is not recommended. Light daily activities, such as walking, can be resumed immediately after a concussion, even during the initial 24- to 48-hour period of relative rest.¹
• Returning to school/work and returning to sports happen in parallel.
• Each stage of returning to sports lasts at least 24 hours. A slight and brief increase in symptoms may be acceptable during the early stages. Symptoms must have resolved before engaging in activities that involve a risk of contact, collision, or fall.
• A healthcare professional may prescribe endurance exercises tailored to the symptoms as early as 2 to 10 days after a sports-related concussion. In adolescent athletes, this approach has reduced the risk of symptoms lasting longer than one month, compared with stretching.^{1, 3}

This article provides you with the step-by-step protocol. To understand the symptoms, consult our article on concussions.

What are the stages of recovery from a concussion?

Recovery from a concussion begins with 24 to 48 hours of relative rest, followed by a gradual resumption of activities. Returning to school or work proceeds in tandem with returning to sports, depending on the symptoms and the risk associated with each activity.

Step 1: Activities That Help Manage Symptoms

During the first 24 to 48 hours, relative rest involves reducing strenuous activities without requiring complete inactivity.

• Do a little reading, if she'll let me
• Take short walks
• Light cooking
• Reduce or stop the activity if symptoms increase by more than two out of ten points or last for more than one hour
• Avoid lying in bed all day in a dark room

After at least 24 hours, proceed based on your symptoms

After Stage 1, the return to school or work proceeds alongside the return to sports. Each person’s progress depends on their individual tolerance.

In the studies, 93% of the athletes had returned to school full-time within 10 days, without any further accommodations. This percentage does not determine how long it takes for an individual to recover.^{1, 2}

Back to School or Back to Work

1. Step 1: During the first 24 to 48 hours, combine relative rest with short, tolerable daily activities.
2. Step 2: Start reading, doing simple homework, or checking emails for short, manageable periods, then gradually increase the time.
3. Step 3: Return to school or work on a part-time basis, with the necessary breaks and accommodations.
4. Step 4: Gradually increase the duration until you reach full days.

Return to sport

1. Step 1: During the first 24 to 48 hours, combine relative rest with daily activities that you can tolerate.¹
2. Step 2: Start with low-intensity walking or stationary cycling, then gradually increase the intensity to a moderate level based on your tolerance, without risk of falling or hitting your head.
3. Step 3: Perform sport-specific exercises without the risk of contact, collisions, or falls.
4. Step 4: Resume non-contact training and gradually increase the intensity.
5. Step 5: Resume full-contact training after receiving approval from a healthcare professional.
6. Step 6: Resume games and competitions.

Each stage of the return-to-play process lasts at least 24 hours. During stages 1 through 3, an increase of no more than two out of ten points lasting less than one hour is acceptable. If the increase is greater than that, stop and try that stage again the next day. Before stage 4, a healthcare professional must confirm that symptoms and other concussion-related issues have resolved, even during and after exercise. Authorization is required before proceeding to this stage and before engaging in any activity that carries a risk of falling or physical contact. Students must also have completed their return to school. If symptoms reappear during stages 4 through 6, stop, return to stage 3, and consult a physician or a specialized nurse practitioner. New authorization is required before proceeding to stage 4.

In Quebec, a trained physical therapist who regularly assesses concussions may also authorize a return to sports once recovery is complete. However, a physician or specialized nurse practitioner must reassess the situation if there are warning signs, an unusual worsening of symptoms, or any other health issue affecting the brain or spinal cord—or one that complicates their assessment. This reevaluation is also necessary after a concussion within the past year or at least two previous concussions. Persistent symptoms require follow-up with several professionals, including a physician or a specialized nurse practitioner.⁴

A full return to school or work must precede a return to sports without restrictions. A person who is not progressing as expected may need an individualized plan.

In studies, a return to sports without restrictions most often occurs within the first month, with an average of about 19.8 days. This average varies widely from one study to another and from one person to another.^{1, 2}

What accommodations can help a student in school after a concussion?

At school, accommodations allow for a gradual return: starting with homework assignments, returning to class without exams or additional pressure, taking breaks in a quiet place, and limiting physical education classes.

• Start with homework without returning to the classroom
• Resume classes without additional pressure (no exams or homework)
• Be able to take breaks in a quiet place
• Allow students to go to their classes before everyone else to avoid an overly noisy and busy environment.
• Limit physical education classes

What accommodations make it easier to return to work after a concussion?

Workplace accommodations make it easier to return to work by first allowing employees to work remotely, take breaks in a quiet place, and perform less demanding tasks.

• Start with telecommuting tasks without returning to the office
• Be able to take breaks in a quiet place
• Perform tasks that are less stressful and less demanding

The treatment plan should be tailored to each individual. If you are unable to progress through the steps or if your symptoms worsen, consult a healthcare professional. After a head injury, call 911 if you experience seizures, repeated vomiting, new weakness, difficulty staying awake, or a headache that worsens and persists. Symptoms that last longer than four weeks are considered persistent in children, adolescents, and adults.¹

Where can I learn more about concussions?

You can learn more about concussions on our concussion page and in our article on the myths and facts about concussions. These resources explain the symptoms, common myths, and the stages of recovery.

Episode 6 of the "Parle-moi de santé" podcast

Episode 6 of the “Parle-moi de santé” podcast, hosted by physical therapist Alexis Gougeon, focuses on concussions.

References

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1. Patricios JS, Schneider KJ, Dvorak J, Ahmed OH, Blauwet C, Cantu RC, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport—Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695-711. (Back to sections: 1, 2, 3, 4, 5, 6, 7)
2. Putukian M, Purcell L, Schneider KJ, Black AM, Burma JS, Chandran A, et al. Clinical recovery from concussion—return to school and sports: a systematic review and meta-analysis. Br J Sports Med. 2023;57(12):798-809. (Back to sections: 1, 2, 3)
3. Leddy JJ, Master CL, Mannix R, Wiebe DJ, Grady MF, Meehan WP, et al. Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomized controlled trial. Lancet Child Adolesc Health. 2021;5(11):792-799. (Back to section: 1)
4. Quebec College of Physicians, Quebec Professional Order of Physiotherapy. Authorization to Resume Sports Activities After a Concussion or Mild Traumatic Brain Injury: A Clarification Regarding the Role of Physical Therapists. 2025. (Back to section: 1)