Concussion: what recovery looks like, why strict rest is out and how physical therapy can help

A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head, or by a hit to the body that makes the head and brain move quickly back and forth [1]. Doctors may call it “mild” because it is usually not life-threatening, but its effects can be serious [2]. It can happen on the field, in a fall or in a car crash. In 2017, 15.1% of US high school students reported at least one concussion from sports or physical activity in the past year [3].

If you think someone may have a serious head injury, go straight to the danger signs at the end of this article.

Common symptoms

Some symptoms show up right away, and others may not appear for hours or days [2]:

Type	Symptoms
Physical	Headache, dizziness or balance problems, nausea or vomiting early on, vision problems, sensitivity to light or noise, feeling tired
Thinking	Trouble concentrating, feeling slowed down or foggy, memory problems
Emotional	Irritability, anxiety, sadness, feeling more emotional
Sleep	Sleeping more or less than usual, trouble falling asleep

Source: CDC, information for adults [2].

How long does recovery take?

The CDC says most people with a mild TBI or concussion feel better within a couple of weeks [4], and most children within 2 to 4 weeks [5]. Recovery may be slower in older adults and in people who have had a brain injury before [2].

Here is what studies of athletes show:

• Back to school or learning8.3 days
• Symptom free14.0 days
• Back to sport19.8 days

Source: Putukian et al., British Journal of Sports Medicine, 2023 [6]. Athletes only, and study results varied widely. Bars are scaled to 20 days.

Symptoms lasting more than 4 weeks are considered persistent and deserve a full clinical assessment [7].

A note on the evidence: most of the research in this article was done in athletes, many of them teenagers. It is the best guide we have, but people injured in falls or car crashes may recover differently, and the international consensus statement is about sport concussion [7].

Why strict rest is no longer the advice

Not long ago, people were told to rest in a dark room until every symptom disappeared. The evidence has moved on. The 2022 international consensus concluded that strict rest until symptoms are completely gone is not beneficial, and that clinicians should avoid recommending complete rest and isolation, even in the first 24 to 48 hours [7].

What is recommended instead:

• First 1 to 2 days: relative rest, which still includes everyday activities and reduced screen time [7]. Light activity, such as walking, is fine as long as it does not more than mildly worsen symptoms [7].
• After that: ease back into your regular activities, even with some mild symptoms [8]. Time off from work or school is usually no more than 1 to 2 days [8].

The trials behind this change:

Study	Who	What was compared	Result
Thomas, 2015 [9]	Ages 11 to 22, seen in an emergency department	5 days of strict rest vs. usual care	Strict rest offered no added benefit, and that group reported more symptoms
Leddy, 2019 [10]	Ages 13 to 18, within 10 days of injury	Aerobic exercise below symptom level vs. stretching	Median recovery 13 days vs. 17 days
Leddy, 2021 [11]	Ages 13 to 18	Heart rate targeted aerobic exercise vs. stretching	48% lower risk of persistent symptoms
Macnow, 2021 [12]	Ages 12 to 25, seen in an emergency department	Screens allowed vs. avoided for 48 hours	Median recovery 8 days with screens vs. 3.5 days without

“Exercise” here means individually prescribed activity below the level that brings on symptoms. It does not mean pushing through the pain. And the screen time study does not mean avoiding screens for weeks: the consensus says reducing them helps in the first 48 hours but may not be effective after that [7].

How physical therapy can help

The physical therapy guideline for concussion recommends that physical therapists first screen for signs of a more serious injury, including the neck, and refer patients when needed [13]. From there, care depends on your symptoms [13]:

• Education: relative rather than strict rest, sleep, and how to pace your return to activity
• Aerobic exercise: a symptom-guided, progressive program for people who do not tolerate exertion or plan to return to vigorous activity (strongest level of recommendation)
• Neck treatment: exercise and hands-on therapy when the neck and upper back are involved, which can happen with headache, dizziness or neck pain
• Vestibular and eye-movement rehab: an individualized plan from a therapist with the right training, for dizziness and balance or vision problems
• Balance and coordination training

The international consensus recommends this kind of neck and balance rehabilitation if dizziness, neck pain or headaches last more than 10 days [7]. In one small trial of young athletes with those symptoms, 73% of those who received it were medically cleared within 8 weeks, compared with 7% of those who did not [14]. The study had only 31 participants, so the true size of the benefit is uncertain.

Going back to sports, driving and work

• Same day: if a concussion is suspected, remove the athlete from play right away and keep them out the day of the injury and until cleared by a health care provider [15].
• Return to sport happens in steps, each usually taking at least 24 hours, so expect at least a week; a full return can take up to a month [7].
• Repeat injury: a second brain injury before the brain has healed may slow recovery or increase the chance of long-term problems, especially in teens and young adults [2].
• Driving and work: ask your health care provider for written instructions on when you can safely return to activities such as work, school and driving [8].

Danger signs: call 911

In rare cases, a dangerous blood clot can crowd the brain against the skull. The CDC says the people checking on you should call 911 or take you to an emergency department right away if you [4]:

• Have a headache that gets worse and does not go away
• Experience weakness, numbness, decreased coordination, convulsions or seizures
• Vomit repeatedly
• Have slurred speech or unusual behavior
• Have one pupil (the black part in the middle of the eye) larger than the other
• Cannot recognize people or places, get confused, restless or agitated
• Lose consciousness, look very drowsy or cannot be woken up

For children, call 911 or go to the emergency department for any of those signs, or if the child will not stop crying and cannot be consoled, or will not nurse or eat [4].

The takeaway

• Most people feel better within weeks, though some take longer.
• Strict rest is out. Take it easy for a day or two, then gradually return to activity.
• Symptoms that last more than a few weeks deserve an evaluation.
• Physical therapy can guide your return to exercise and treat neck, dizziness and balance problems.
• Never return to sport the same day, and know the danger signs.

This article is not a substitute for medical care. See a doctor after a head injury. If you are still dealing with headaches, dizziness or neck pain, you can start physical therapy in Utah without a referral, and we will refer you to the right specialist if you need one.