An initial 48-hour period of rest followed by light aerobic exercise for the next two weeks ensures that players are active but does not return them to sport specific drills any quicker. The key to light aerobic activity is that this does not provoke or exacerbate symptoms. Personally we use a +3 increase in symptom severity on a visual analog scale as an indicator of lack of tolerance to the activity (over-doing it). Following this period, players can return to sport specific training, progressing through the various stages at differing rates dependent upon age, providing they are asymptomatic. Those still symptomatic should be referred for additional management.

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Prior to any return to contact-based training, players must receive a medical clearance from a registered medical practitioner. This should involve a thorough assessment including the following, with normative data providing reference ranges3:

‍1. Symptom score and severity score using SCAT 5 assessment tool ( <5 on each scale)
2. Neurocognitive assessment (SAC) using SCAT 5 assessment tool (>24)
3. Balance error scoring assessment (<5 errors single leg, <3 errors tandem gait)
4. Tandem gait walk test (<14 seconds)
5. Full pain-free symmetrical range of movement of the cervical spine
6. Completion of GRTP with no recurrence of symptoms (Stages 1-4)

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References

1. Leddy J, Hinds A, Miecznikowski J, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: A Randomized Trial. Clin J Sport Med 2017;0.
2. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. Journal of Physical Medicine and Rehabilitation 2016:S91-S100.
3. Fuller G, Govind O, Tucker R, Raftery M. Sport concussion assessment tool—Third edition normative referencevalues for professional Rugby Union players. J Sci Med Sport 2017.

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