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Concussion injuries are highly specific to the individual; not all concussions look or feel the same. Patients with very similar sports concussion injuries may experience vastly different recovery timelines.
This variability is due to the fact that concussions are functional injuries, meaning that symptoms arise from changes in the body’s systems, such as autonomic nervous system dysfunction, musculoskeletal injury, inflammation and visual/eye tracking issues. These disruptions cause symptoms to manifest in unique and varied ways.
This is particularly true for athletes, whose brains and bodies are subjected to high demands and stimuli during sports. For optimal performance, all systems must work seamlessly, which is why recovery can be so complex.
In this article, we will explore the typical recovery time for concussions, strategies to speed up recovery, and how to minimize the time you are sidelined from sports and daily life.
Typical Recovery Time.
The overall recovery time from a concussion can be viewed in two primary ways:
Metabolic recovery
Symptomatic recovery/relief.
Metabolic Recovery:
This refers to how quickly the body returns to normal functioning at a metabolic and cellular level after a traumatic brain injury. Seminal work in 2001, updated in 2014, discovered there is a “neurometabolic cascade” after a concussion. This cascade helps to explain the electrolyte, blood flow, and energy disruptions seen in acute and chronic concussions (1). The recovery timeline following this cascade is crucial when considering a return to sports or other high-risk activities. Metabolic recovery is arguably the most important aspect to monitor for safe reintegration into such activities because the risk of repeat injury during a metabolically vulnerable period could result in more severe and potentially permanent injury.
The typical period of metabolic recovery has been well studied. A 2013 paper by Vagnozzi and colleagues, demonstrated the recovery time typically ranges from 22 to 30 days (2).
Symptomatic Relief:
Another aspect of perceived concussion recovery is when the patient reports complete symptom relief. In the early stages of concussion care, achieving symptom relief is a primary focus of the medical professional’s attention, however, it is not a marker of full recovery.
Research indicates that symptoms do not necessarily correlate with the extent of harm or metabolic recovery. For example:
Many patients may become symptom-free at rest but remain in a vulnerable stage of recovery (e.g., still only 1 week from their injury).
On the flip side, in cases of Post Concussion Syndrome (PCS), patients may have fully recovered metabolically but still experience symptoms. This is due to the fact that symptom recovery from a concussion is more complex and unpredictable compared to metabolic recovery.
While most individuals will follow a typical metabolic recovery timeline, their symptoms can vary significantly. Factors such as pre-injury health conditions, current comorbidities, lifestyle, and biomechanics contribute to these unique symptoms and recovery timelines.
There is no fixed timeline for symptom relief following a concussion, as it is highly individualized and influenced by multiple factors. Research indicates that approximately 60% of individuals experience symptom relief within 5-7 days post-concussion (3,4,5,6).
However, while early symptom relief is a positive sign, it does not equate to full recovery. For complete and safe recovery, the metabolic recovery timeline must also be taken into account. Below is a study from 2020 that followed 822 patients over a 2-year period at a sports concussion clinic in New Zealand. This study looked at both symptomatic and metabolic recovery.
Reference: Kara, S., Crosswell, H., Forch, K., Cavadino, A., McGeown, J., & Fulcher, M. (2020). Less than half of patients recover within 2 weeks of injury after a sports-related mild traumatic brain injury: a 2-year prospective study. Clinical journal of sport medicine, 30(2), 96-101.PMID: 32132366
They found that most (~70-80%) individuals, with some variation across ages, recover in 4 weeks. “Recovery” was defined using both symptom and physical exam criteria that would indicate metabolic recovery:
PCSS <5 for males
PCSS <6 for females
Resolution of any abnormal exam findings
Normal Exercise Tolerance (85-90% HRmax while asymptomatic)
Common Questions of Concussion Recovery Time.
Q: How long does it take to recover from a concussion?
A: Again, recovery time varies, but research shows that metabolic recovery usually takes 22 to 30 days. Symptom relief can occur within 5-7 days after a concussion occurs for approximately 60% of individuals, but full recovery must consider both metabolic and symptomatic recovery. Data tells us that with active rehab that will occur in ~4 weeks for most people (See graph above).
Q: Why is metabolic recovery important for returning to sports or physical activity?
A: Metabolic recovery ensures the body has restored normal function at a cellular level, making it crucial for safely returning to sports or high-risk activities. Without full metabolic recovery, the risk of further or more severe injury increases as depicted below.
Q: Can symptoms disappear before full recovery is achieved?
A: Yes, symptoms can disappear before full metabolic recovery is achieved. This is why it is important to monitor both symptom relief and metabolic recovery to ensure complete and safe healing.
Post-Concussion Syndrome.
A term that is often used synonymously with PCS is ‘persistent concussion symptoms’. According to the newly published Amsterdam consensus statement, PCS refers to the presence of symptoms >4 weeks after injury across children, adolescents, and adults.
As highlighted above we discussed that the majority of patients, around 60%, will achieve symptom relief around 5-7 days post injury. While this doesn’t indicate full recovery and clearance to return to sport, it should still be the goal of care to abolish symptoms as quickly as possible.
The other 30-40 percent of patients will go on to experience concussion symptoms lasting longer than the normal length of metabolic healing. These patients are considered to have persistent concussion symptoms (PCS).
Persistent symptoms can last months to years without appropriate rehab. PCS is not due to structural or permanent pathology. PCS is more related to functional disturbances outlined below.
The Number 1 Strategy to Shorten Symptom Duration and Speed Up Recovery.
There are numerous predictors of concussion prognosis, including the type of sporting event, sex, age, and mechanism of injury. However, research highlights one key predictor that stands out as the most critical factor in determining the speed of symptom relief and recovery – how quickly the patient is seen by a trained concussion specialist.
Patients with a shorter duration between the initial injury and first evaluation demonstrated less time with reported symptoms and ultimately a faster recovery.
Desal et al. 2019 conducted a study on factors affecting recovery trajectories in pediatric female patients (7). The study revealed that females had a longer time between a suspected concussion injury and evaluation, with an average of 15 days post-injury compared to 9 days for males. They also found that females took longer to return to non-contact sporting events (13 days versus 7 days for males) and to achieve full sport clearance (119 days versus 45 days for males).
However, the most exciting finding was that when both females and males were evaluated by a trained concussion specialist within 7 days post-injury, there was no difference in recovery time between the sexes.
This study demonstrates that we can effectively shorten recovery time by having our concussed athletes seen by a trained concussion specialist within the first week of injury.
Another study by Kontos et al. 2020 found that among 162 adolescent athletes with concussions, those who received clinical care within 7 days recovered more quickly and were less likely to experience prolonged recovery times compared to those who were seen 8-20 days post-injury (8).
“In this study, athletes who were evaluated within a week of injury recovered in a mean of 20 days faster than those athletes seen 2 to 3 weeks postinjury. One reasonable explanation for this difference is the earlier initiation of active rehabilitation strategies, including exertion progression and opportunity to start structured physical therapy (eg, on vestibular, vision, and cervical systems).”
-Kentos et al 2020
Considerations When Returning to Performance Sports.
Following a sports injury, it is crucial to return to physical activity as safely as possible. The return-to-play protocol following an mTBI should be closely monitored by a concussion specialist due to the increased risk of severe injury if an athlete returns to sport too soon (e.g., 7 day symptom recovery).
All athletes returning to their sport must first meet specific criteria to ensure their readiness. The primary requirement is that the athlete must be asymptomatic at rest. This means they should be able to return to full-time schoolwork and daily activities without any symptoms. Additionally, the athlete must demonstrate the ability to remain symptom-free during steady-state cardiovascular exercise up to their maximum heart rate, which is assessed using the Buffalo Concussion Treadmill Test (BCTT).
For high-performance athletes participating in high-contact sports, passing the Chicago Blackhawks Protocol is essential. This protocol tests the athlete’s ability to handle “in-game” physical and cognitive demands, ensuring they can perform at their highest level without symptoms.
In addition to physical assessments, other mechanisms can be tested to ensure an athlete is ready to return to their sport.
When athletes are asymptomatic, meaning they are not experiencing symptoms, it is crucial to rely on objective tests. Objective tests are performance-based and do not depend on the athlete’s subjective reporting of how they feel. This approach reduces the likelihood of false claims of symptoms and provides a more accurate assessment of the athlete’s condition.
Athletes with an active baseline test can more accurately determine when full recovery from a concussion is achieved. This includes testing visual processing speed, reaction time, and neurocognitive performance. By comparing pre- and post-injury test scores, physicians can make a more informed and safer decision about the athlete’s return to play if the scores align with baseline levels.
In summary, the return-to-play process should be closely monitored by a concussion specialist, especially for athletes returning to high-risk sports. To ensure a safe return to sport, an athlete must meet the following criteria:
Be asymptomatic at rest.
Be asymptomatic during steady-state cardiovascular exercise (up to maximum heart rate or perceived maximum exhaustion).
Be asymptomatic under dynamic exercise conditions (tested through the Chicago Blackhawks Protocol).
Complete and pass baseline testing and other pre-injury objective measures
Symptom resolution is an essential aspect of full recovery. While most individuals’ brain injuries heal within a typical timeframe, some may experience lingering symptoms toward the end of their metabolic recovery timeline. These lingering symptoms can indicate incomplete recovery at the metabolic level, highlighting the need for healthcare providers to continuously monitor symptom progression and regression.
As athletes advance in their return-to-sport protocol, additional assessments, such as retesting baseline measures or, for high-performance athletes, tests like the Chicago Blackhawks protocol, may be performed. These evaluations help ensure that normal brain function is restored before resuming performance sports, which is crucial for a safe and effective return.
Conclusion.
Concussion symptom timelines are highly individualized and unique. Multiple factors can influence whether an individual experiences symptoms for a short duration or endures lasting symptoms following a concussion.
While metabolic recovery typically occurs within 22-30 days post concussion, research shows that approximately 70-80% of acute concussion cases that undergo active rehab experience full recovery within 4 weeks. The other 30% who experience symptoms persisting beyond 4 weeks are categorized as Post Concussion Syndrome (PCS). PCS suggests that prolonged symptoms are due to functional disturbances rather than structural damage, as full metabolic recovery has already taken place.
In cases of PCS, symptoms can last months to years and may be prolonged by factors such as pre-existing conditions, lifestyle factors, and the quality of concussion care received. The primary predictor of shorter symptom duration and quicker return to sports is the time between injury and evaluation by a concussion specialist.
Numerous studies have shown that individuals who are evaluated sooner after their head injury experience shorter recovery periods, faster returns to sports, and less time with reported concussion symptoms.
To find a concussion clinic near you for further assessment and rehab click here!
References
Giza, C. C., & Hovda, D. A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75, S24-S33.
Vagnozzi R, Signoretti S, Cristofori L, et al. Assessment of metabolic brain damage and recovery following mild traumatic brain injury: a multicentre, proton magnetic resonance spectroscopic study in concussed patients [published correction appears in Brain. 2013 Nov;136(Pt 11):i1. Marziale, Simone [corrected to Marziali, Simone]]. Brain. 2010;133(11):3232-3242.
Zemek R, Barrowman N, Freedman SB, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED [published correction appears in JAMA. 2016 Jun 21;315(23):2624].
Grubenhoff JA, Currie D, Comstock RD, Juarez-Colunga E, Bajaj L, Kirkwood MW. Psychological Factors Associated with Delayed Symptom Resolution in Children with Concussion. J Pediatr. 2016;174:27-32.e1. doi:10.1016/j.jpeds.2016.03.027
Howell DR, Zemek R, Brilliant AN, Mannix RC, Master CL, Meehan WP 3rd. Identifying Persistent Postconcussion Symptom Risk in a Pediatric Sports Medicine Clinic. Am J Sports Med. 2018;46(13):3254-3261.
Ewing-Cobbs L, Cox CS Jr, Clark AE, Holubkov R, Keenan HT. Persistent Postconcussion Symptoms After Injury. Pediatrics. 2018;142(5):e20180939.
Desai N, Wiebe DJ, Corwin DJ, Lockyer JE, Grady MF, Master CL. Factors Affecting Recovery Trajectories in Pediatric Female Concussion. Clin J Sport Med. 2019;29(5):361-367.
Kontos AP, Jorgensen-Wagers K, Trbovich AM, et al. Association of Time Since Injury to the First Clinic Visit With Recovery Following Concussion. JAMA Neurol. 2020;77(4):435-440.
Dr. Denner is a highly skilled Chiropractic Physician and licensed Athletic Trainer based in Charlotte, North Carolina. Specializing in sports medicine and rehabilitation, he utilizes his unique background in manual therapy, functional rehabilitation, joint manipulation, and neuromuscular stabilization to effectively treat a wide range of musculoskeletal conditions.
As the owner and treating physician at Denner Chiropractic & Performance, Dr. Denner brings extensive experience and a comprehensive approach to patient care. With a focus on personalized, functional treatment plans, he empowers his patients to take an active role in their recovery.