Concussion Recovery Timeline of High School Athletes Using A Stepwise Return-to-Play Protocol: Age and Sex Effects.

Tamura K, Furutani T, Oshiro R, Oba Y, Ling A, Murata N. J Athl Train. 2019 Dec 26. doi: 10.4085/1062-6050-452-18. [Epub ahead of print]

Full Text Freely Available

Take-Home Message

On average, a younger or female adolescent athlete may take ~3 to 4 days longer than their peers to be cleared to return to light aerobic exercise after a concussion.


Many clinicians use a multistep progression to return a patient to activity after a concussion (e.g., return to school, light aerobic activity, and then sport-specific drills). Unfortunately, the literature fails to provide a thorough understanding of the recovery timeline and how it may differ by age or sex. Therefore, the authors of this study went back and looked at data from 726 athletes that sustained a concussion between 2010-2012 to determine their recovery timeline. Athletic trainers from the 57 participating high schools assessed all reported concussions using a standard concussion-management protocol. The authors evaluated days spent within each of the following 7-steps of the return-to-play progression: 1) Complete cognitive rest, 2) Full return to school, 3) Light aerobic exercise, 4) Running progression, 5) Noncontact training drills and weight training, 6) Full-contact practice or training, and 7) Return to game.

Athletic trainers from the participating schools evaluated and reported on 1,883 athletes with concussions; however, the authors excluded over 50% of athletes because of incomplete reports on the dates of each recovery step. Overall, the 726 athletes recovered in ~20 days (steps 0 through 6). Females took ~ 3 days longer to recover from a concussion compared to males (~22 days vs. ~19 days). Over half of the recovery time was spent in steps 0 through 3 (~14 days). Specifically, the transition from return to school to light exercise took the longest among the transitions between steps (10 days). Younger athletes (14-16-year-olds) took ~4 days longer to start light aerobic activity compared to 17-year olds (~15 days compared to ~11 days). This led to younger athletes taking ~4 days longer to return to play compared with 17-year olds (~21 days vs. ~17 days).


The authors of this study were the first to break down the average length of time it takes an athlete to complete each step during a concussion recovery progression. Clinicians could add these averages into concussion education presentations to raise awareness about what a “normal” recovery is but with a reminder that each patient may recover faster or slower than the average. Reminding people that the average recovery is not what everyone experiences could decrease anxiety about their return to play. The longest step with the most variability was after return to school while waiting to be cleared for light aerobic exercise. Hence, we need more specific return-to-school concussion management protocols (e.g., explanation on how to educate and deliver school modifications). Furthermore, recent research suggests that early sub-symptom aerobic exercise may speed up recovery. Therefore, a patient could start aerobic exercise before symptoms resolution. This suggests that if athletic trainers implement aerobic exercise before symptom resolution their progression to step 4 could be earlier and lead to a quicker return to play. Additionally, the authors found that younger athletes take longer to recover. This complements a recent NCAA CARE Consortium study that found that collegiate athletes recovered in ~16 days, which is similar to the 17-year olds in this new study. Therefore, clinicians need to account for age during the recovery phase and more studies should consider other factors that play a role in prolonged recovery for younger athletes. It is important to note that these changes may not be just physiological. Medical professionals may need to consider if they are more conservative when clearing a younger patient and if females may be more truthful than males when disclosing symptoms, which could lead to longer times to return to play. Currently, athletic trainers should be aware of this concussion recovery timeline and ensure they have a sound return-to-school concussion management plan and should educate athletes, parents, teachers, administrators, and coaches regarding the stages and what needs to occur at these stages for safe return to play. Furthermore, this timeline can help patients, parents, and coaches have appropriate expectations for their recovery.

Questions for Discussion

How long do your athletes take to recovery? Do you note a time that takes more time or is more variable than others?

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

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