What Concussion Recovery Actually Looks Like

What Concussion Recovery Actually Looks Like

Concussion is one of the most widely discussed injuries in sport — and also one of the most misunderstood. The old model (rest in a dark room until all symptoms are gone) has been substantially revised by research over the past decade. What the evidence now supports looks quite different: active, graduated recovery that begins within days of the injury and progresses systematically toward return to sport.¹

A concussion is a functional brain injury — a disruption to normal neurological function following a biomechanical force to the head, neck, or body. There is no structural lesion visible on standard MRI or CT. The injury is physiological: altered energy metabolism, disrupted neurotransmitter function, and changes in cerebral blood flow regulation that create the symptom complex most people recognize — headache, cognitive fog, sensitivity to light and noise, sleep disruption, and emotional lability.¹

The Old Approach and Why It Changed

For years, the standard recommendation was complete rest until symptom-free, followed by a graduated return-to-sport protocol. The logic made intuitive sense: the brain is injured, so don't stress it. The evidence, however, showed that prolonged rest produced worse outcomes — higher rates of persistent post-concussion symptoms, greater deconditioning, and increased anxiety — compared to early, carefully introduced sub-threshold aerobic activity.²

The current understanding is that the injured brain benefits from controlled aerobic exercise, delivered at an intensity below the symptom threshold. This sub-threshold activity supports autonomic nervous system recovery, improves cerebral blood flow regulation, and helps the brain return to normal physiological function faster than rest alone.²

The Cervical Spine Component

Concussion rarely occurs in isolation from cervical spine injury. The same mechanism that produces a concussion — rapid acceleration-deceleration of the head — also loads the cervical joints, muscles, and ligaments. Cervicogenic symptoms (neck pain, cervicogenic headache, dizziness related to upper cervical joint dysfunction) frequently coexist with concussion and can extend recovery if not specifically identified and treated.³

This is clinically important because some symptoms attributed to the concussion — particularly headache and dizziness — may have a cervical origin that responds well to manual therapy and cervical rehabilitation. A post-concussion assessment that doesn't examine the cervical spine is incomplete.

The Return-to-Sport Protocol

The Concussion in Sport Group's stepwise return-to-sport protocol — endorsed in the 2023 international consensus statement — guides progression through six stages: symptom-limited activity, light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact training following medical clearance, and return to competition. Each step requires 24 hours without symptom exacerbation before advancing.¹

This graduated approach applies the same principle of progressive loading that governs rehabilitation for any musculoskeletal injury: the system — in this case the brain — needs to be progressively challenged without exceeding its current tolerance. Jumping steps in the protocol because the person feels well is the mechanism behind the concussions that don't resolve on a normal timeline.⁴

Red Flags and When to Refer

The vast majority of concussions resolve within 7–14 days in adults and within a month in adolescents. When symptoms persist beyond these timeframes — termed persistent post-concussion symptoms — a multidisciplinary approach is indicated, potentially including neuropsychology, vestibular rehabilitation, vision therapy, and cervical physiotherapy depending on the symptom profile.

Red flags that require immediate emergency care include: loss of consciousness lasting more than a minute, repeated vomiting, seizure activity, deteriorating neurological status, and severe or worsening headache. These findings are not typical of uncomplicated concussion and require urgent imaging to rule out structural injury.

At Boreal Spine & Sport, post-concussion assessment includes cervical spine examination alongside the standard concussion evaluation — recognizing that the neck is almost always involved and that addressing cervicogenic contributions improves the trajectory of recovery.

References

1. Patricios JS, Schneider KJ, Dvorak J, 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.
2. Leddy JJ, Haider MN, Ellis MJ, Willer B. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262–270.
3. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930–934.
4. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–280.