In 2023, the Sport and Recreation Alliance, alongside the Government, published the first UK-wide Concussion Guidelines for Grassroots Sport, which were updated in November 2024.
What can be the consequences of concussion?
Red flags - require urgent medical assessment
Visible clues (signs) of concussion
Symptoms of concussion at or shortly after injury
Immediate management of a suspected concussion
Anyone with a suspected concussion should
Anyone with a suspected concussion should not
Following a suspected concussion, what's your role?
Concussion recovery time varies
Graduated return to activity (education/work) and sport
The following guidance is intended to provide information on how to recognise concussion and on how it should be managed from the time of injury through to a safe return to education, work and playing sport.
This information is intended for the general public and for individuals participating in all grassroots sports – primary school age and upwards - where Healthcare Professionals are typically not available onsite to manage concussed individuals. This information is for all those participating in grassroots sport, including disabled people. However, where impairment-specific issues arise further advice should be sought.
This document contains general medical information, but this does not constitute medical advice and should not be relied on as such. Nor is this guidance a substitute for medical advice from a qualified medical practitioner or healthcare provider. You must not rely on this guidance as an alternative to seeking medical advice from a qualified medical practitioner or healthcare provider. In particular, if you have any questions or concerns about a particular medical matter you should immediately consult a qualified medical practitioner or healthcare provider. If you think you may be suffering from a medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because of information contained in this guidance.
At all levels in all sports, if an individual is suspected of having a concussion, they must be immediately removed from play.
No-one should return to competition, training or Physical Education (PE) lessons within 24 hours of a suspected concussion. Anyone with a suspected concussion should NOT drive a motor vehicle (e.g. car or motorcycle), ride a bicycle, operate machinery, or drink alcohol within 24 hours of a suspected concussion and commercial drivers (HGV etc.) should seek review by an appropriate Healthcare Professional before driving.
All those suspected of sustaining a concussion should be assessed by an appropriate onsite Healthcare Professional or by accessing the NHS by calling 111 within 24 hours of the injury. If there are concerns about other significant injury or the presence of ‘red flags’ then the player should receive urgent medical assessment onsite or in a hospital Accident and Emergency (A&E) Department using ambulance transfer by calling 999 if necessary.
Anyone with concussion should generally rest for 24-48 hours but can undertake easy activities of daily living and walking, but must avoid intense exercise, challenging work, or sport. They can then progress through the graduated return to activity (education/work) and sport programme. Anyone with symptoms that last longer than 28 days should be assessed and managed by an appropriate Healthcare Professional (e.g. their General Practitioner [GP]).
Key points:
Concussion is a traumatic brain injury resulting in a disturbance of brain function. It affects the way a person thinks, feels and remembers things.
Loss of consciousness (being ‘knocked out’) occurs in less than 10% of concussions and is not required to diagnose concussion. However, anyone who loses consciousness because of a head injury has had a concussion.
Anyone with suspected concussion should be immediately removed from the field of play and assessed by an appropriate Healthcare Professional or access the NHS by calling 111 within 24 hours of the injury.
Concussion can affect people in four main areas,
Physical (e.g. headaches, dizziness, vision changes)
Mood (e.g. short tempered, sad, emotional)
Mental processing (e.g. not thinking clearly, feeling slowed down)
Sleep (e.g. not being able to sleep or sleeping too much)
There may be times when the person may have no visible signs such as looking blank and being off balance. It can be very difficult to differentiate concussion from other more serious injuries, such as bleeding in the brain. Other significant injuries such as injuries to the neck or face can also occur along with concussion.
Playing on with symptoms of concussion can make them worse, significantly delay recovery, and, should another head injury occur, result in more severe injury and in rare cases, death (known as second impact syndrome). This is why it is so important to remove anyone with suspected concussion from the at-risk activity immediately.
Concussion can be caused by a direct blow to the head but can also occur when knocks to other parts of the body result in rapid movement of the head (e.g. whiplash type injuries).
A history of previous concussion(s) increases the risk of sustaining a further concussion, which may then take longer to recover.
A history of a recent concussion also increases the risk of other sport-related injuries (e.g. musculoskeletal injuries).
Concussions can happen at any age. However, children and adolescents:
All those suspected of sustaining a concussion should be assessed by an appropriate onsite Healthcare Professional or by accessing the NHS by calling 111 within 24 hours of the injury. If there are concerns about other significant injury or the presence of ‘red flags’ then the player should receive urgent medical assessment onsite or in a hospital Accident and Emergency (A&E) Department using ambulance transfer by calling 999 if necessary.
If any of the following ‘red flags’ are reported or observed, then the player should receive urgent medical assessment from an appropriate Healthcare Professional onsite or in a hospital Accident and Emergency (A&E) Department using emergency ambulance transfer if necessary:
The first symptoms of concussion typically appear immediately or within minutes of injury but may be delayed and appear over the first 24-48 hours following a head injury. Over the next several days, additional symptoms may become apparent (e.g. mood changes, sleep disorders, problems with concentration).
Spotting head impacts and visible clues of concussion can be difficult in fast moving sports. It is the responsibility of everyone – players, coaches, teachers, referees, spectators, and families – to watch out for individuals with suspected concussion and ensure that they are immediately removed from play. Continuing to play following a concussion is dangerous and leads to a longer recovery period.
Remember that the primary aim is to protect the individual from further injury by immediately removing them from play. Return to play should not be permitted until after evaluation by an appropriate Healthcare Professional and the successful completion of a graduated return to activity (education/work) and sport programme.
If any of the following visible clues or symptoms are present following a head injury, the player should be suspected of having a concussion and immediately removed from play or training and evaluated by an appropriate Healthcare Professional.
Any one or more of the following visible clues can indicate a concussion:
Presence of any one or more of the following signs & symptoms may suggest a concussion:
Anyone with a suspected concussion should be IMMEDIATELY REMOVED FROM PLAY.
Once safely removed from play, the player must not be returned to activity that day and until an appropriate Healthcare Professional has excluded concussion or the patient has completed a graduated return to activity (education/work) and sport programme.
If a neck injury is suspected, the player should only be moved by Healthcare Professionals with appropriate training.
Teammates, coaches, match officials, team managers, administrators or parents/carers who suspect someone may have concussion MUST do their best to ensure that the individual is removed from play in as rapid and safe a manner as possible.
Generally, a short period of relative rest (24-48 hours) followed by a gradual stepwise return to normal life and then subsequently sport is the cornerstone of concussion management. In the first 24-48 hours, it is ok to perform mental activities like reading, and activities of daily living as well as walking.
After initial assessment and confirmation of concussion by an appropriate Healthcare Professional onsite or via NHS by calling 111, the graduated return to activity (education/work) and sport programme typically can be self-managed, although severe or prolonged symptoms (over 28 days) should be under the supervision of an appropriate Healthcare Professional and management will depend on the severity of symptoms and the types of symptoms and difficulties that are present. This varies from person to person and is not a ‘one size fits all’ process.
After a 24-48 hour period of relative rest, a staged return to normal life (education/work) and sport at a rate that does not exacerbate existing symptoms, more than mildly, or produce new symptoms is the main aim. This is before return to sport is contemplated.
It is acceptable to allow students to return to school or work activities, and subsequently school or work part-time (e.g. half-days or with scheduled breaks), even if symptoms are still present, provided that symptoms are not severe or significantly worsened. The final stage of return to school or work activity is when the individual is back to full preinjury mental activity, and this should occur before return to unrestricted sport is contemplated.
Similar to the return to education/work progression, the return to sport progression can occur at a rate that does not, more than mildly, exacerbate existing symptoms or produce new symptoms. It is acceptable to begin light aerobic activity (e.g. walking, light jogging, riding a stationary bike etc.), even if symptoms are still present, provided they are stable and are not getting worse and the activity is stopped for more than mild symptom exacerbation. Symptom exacerbations are typically brief (several minutes to a few hours) and the activity can be resumed once the symptom exacerbation has subsided.
Although symptoms may resolve following a concussion, it takes longer for the brain to recover. The aim is to:
Rehabilitate the person – give the brain time to recover.
Most symptoms of a concussion resolve by two to four weeks, but some can take longer. Everyone is unique in their recovery duration which is why completion of a graduated return to activity (education/work) and sport programme is important to reduce the risks of a slow recovery, further brain injury, and longer-term problems. Children and adolescents may take longer to recover than adults.
If symptoms persist for more than 28 days, individuals need to be assessed by an appropriate Healthcare Professional – typically their GP.
Please note that headaches can persist for several months or more, well after the acute injury from the concussion has resolved. They may resemble migraine and may be associated with nausea and sensitivity to light and/or sound. Sometimes they are from a neck injury. Persisting symptoms are not usually due to a more severe brain injury and, if the headache is not increased by mental or physical activity and the frequency and intensity is managed adequately, it should not preclude an individual from returning to school, work and physical activity.
Overview
If symptoms continue beyond 28 days remain out of sport and seek medical advice from a GP
Notes
(NOT before day 21) as long as symptom free at rest for 14 day
*rest until the following day if this activity more than mildly increases symptoms.
Focus - Relative rest period (24-48 hours)
Description of activity - Take it easy for the first 24-48 hours after a suspected concussion. It is best to minimise any activity to 10 to 15-minute slots. You may walk, read and do some easy daily activities provided that your concussion symptoms are no more than mildly increased. Phone or computer screen time should be kept to the absolute minimum to help recovery.
Focus - Return to normal daily activities outside of school or work.
Description of activity -
Focus - Physical Activity (e.g. week 1)
Description of activity -
Comments - There may be some mild symptoms with activity, which is OK. If they become more than mildly exacerbated by the mental or physical activity in Stage 2, rest briefly until they subside.
Focus - Increasing tolerance for thinking activities
Description of activity -
Focus - Light aerobic exercise (e.g. weeks 1 or 2)
Description of activity -
Comments - Progressing too quickly through stages 3 - 5 whilst symptoms are significantly worsened by exercise may slow recovery. Although headaches are the most common symptom following concussion and may persist for several months, exercise should be limited to that which does not more than mildly exacerbate them. Symptom exacerbation with physical activity and exercise is generally safe, brief and is self-limiting typically lasting from several minutes to a few hours.
Focus - Return to study and work
Description of activity - May need to consider a part-time return to school or reduced activities in the workplace (e.g. half-days, breaks, avoiding hard physical work, avoiding complicated study).
Focus - Non-contact training (e.g. during week 2)
Description of activity - Start training activities in chosen sport once not experiencing symptoms at rest from the recent concussion. It is important to avoid any training activities involving head impacts or where there may be a risk of head injury. Now increase the intensity of exercise and resistance training.
Comments - Progressing too quickly through stages 3 - 5 whilst symptoms are significantly worsened by exercise may slow recovery. Although headaches are the most common symptom following concussion and may persist for several months, exercise should be limited to that which does not more than mildly exacerbate them. Symptom exacerbation with physical activity and exercise is generally safe, brief and is self-limiting typically lasting from several minutes to a few hours.
Focus - Return to full academic or work-related activity
Description of activity - Return to full activity and catch up on any missed work.
Focus - Unrestricted training activities (not before week 3)
Description of activity - When free of symptoms at rest from the recent concussion for 14 days can consider commencing training activities involving head impacts or where there may be a risk of head injury.
Comments - Individuals should only return to training activities involving head impacts or where there may be a risk of head injury when they have not experienced symptoms at rest from their recent concussion for 14 days. Recurrence of concussion symptoms following head impact in training should trigger removal of the player from the activity.
Focus - Return to competition
Description of activity - This stage should not be reached before day 21* (at the earliest) and only if no symptoms at rest have been experienced from the recent concussion in the preceding 14 days and now symptom free during pre-competition training.
* The day of the concussion is Day 0 (see example below).
Comments - Resolution of symptoms is only one factor influencing the time before a safe return to competition with a predictable risk of head injury. Approximately two-thirds of individuals will be able to return to full sport by 28 days but children, adolescents and young adults may take longer.
Example 1:
Example 2:
Example 3:
If symptoms continue beyond 28 days – remain out of sport and medical advice should be sought from a GP (which may in turn require specialist referral and review).
Below you will find answers to some frequently asked questions about the Graduated Return to Activity and Sport (GRAS) programme set out above.
1. What is the difference between the Graduated Return to Activity and Sport (GRAS) and the previous Graduated Return to Play (GRTP)?
Importantly the GRAS no longer requires an initial 14- day complete rest period.
After a first week of light exercise/symptom-limited activity, if symptom-free at rest, you will be able to start more demanding physical activities in the second week, provided there is no predictable risk of head contact. Resistance training activities can also be started in this week. Training activities with a predictable risk of head contact can be introduced in week three (but only if symptom-free at rest for 14 days).
2. Do we need to leave 48 hours between stages of the GRAS?
The GRAS is not based around the same strict minimum timing per stage as the GRTP.
As a guide no stage should last less than one day. Stages 5 and 6 involve return to unrestricted training and match play where there may be a predictable risk of head contact. As a consequence, you must have been completely symptom-free at rest for at least 14 days before this. Stage 5 therefore cannot start until Day 15 at the earliest.
3. How do we know when it is appropriate to move between stages 1, 2 and 3 of the GRAS?
There is increasing evidence that low level exercise early after a concussion is helpful in improving brain recovery.
Reflecting this, progressive low-level exercise is encouraged, even if you have mild symptoms. You may, therefore, still progress through stages 1, 2 and 3 even if symptoms are present, providing the activity does not more than mildly exacerbate these symptoms.
Any mild worsening of symptoms is acceptable if they are brief, ideally less than one hour but this can be up to a few hours, and the activity can be resumed once the symptom exacerbation has subsided.
4. How do we know when it is appropriate to move to stages 4, 5 and 6?
You can move into stage 4 when you are symptom-free at rest and have completed stages 1, 2 and 3.
You can move into stage 5 at the earliest on day 15 and must have been symptom-free at rest for a minimum of 14 days and have completed stages 1, 2, 3 and 4.
You can return to play (stage 6) at the earliest on day 21 and must have completed stage 5.
5. What can I do between stage 4 and stage 5 (i.e. do I just follow a ‘normal’ training schedule within the limitations of the stage I am at)?
This is set out in more detail in the GRAS guidance.
Progression should be gradual across all stages of the GRAS and guided by the clinical picture. During the non-contact and contact training phases, there should be a gradual increase in exposure with the aim of being back into the normal training schedule by the end of the week.
6. Is there a requirement for review by a doctor or a healthcare professional when moving through the GRAS guidance?
There is no longer any expectation for review by a doctor or healthcare professional when progressing through recovery, including moving to contact training or return to play.
Individualised case management and/or clinical reviews by a doctor or healthcare professional is considered standard practice in elite settings.
The guidelines state that medical advice should be sought from the NHS by calling 111 if symptoms deteriorate or do not improve by 14 days after the injury. Those with symptoms after 28 days should seek medical advice via their GP.
7. Does concussion management differ for males and females?
Studies comparing data on concussion risk and recovery in male and female athletes are limited but suggest female athletes may be at higher risk and may take longer to recover than male athletes. More research is needed to explore these findings. Meanwhile, managing all concussions individually remains the rule and it is suggested that equivalent concussion management resources be made available to both female and male participants, where at all practical.
8. Does concussion management differ for disabled people?
As with anyone who suffers a concussion, disabled people who have a suspected concussion must be removed from play. The principles of “If In Doubt Sit Them Out” apply. There may be individualised adaptations required for supporting a disabled person, such as facilitating transfers for wheelchair users to help promote rest in the initial phases or using a hand cycle instead of stationary cycling in the later stages of returning to sport.
Disabled people may require a longer initial period of relative physical and cognitive rest prior to starting the return to activity and sport process. This is especially relevant for people with conditions such as cerebral palsy, stroke, or previous moderate/severe traumatic brain injury, where they may already exhibit some degree of neurological impairment. During the GRAS process, it must be established whether symptoms brought on during the GRAS process represent part of the person’s normal functioning, rather than being related to their concussion.
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