Are we as clinicians playing our part to address the increased injury risk following a Sports-Related Concussion?

Active rehabilitation and graded exercise rather than physical rest may help reduce the increased injury risk reported in many recent studies. 

Keywords: Sports-Related Concussion, Rehabilitation, Injury risk

Sports-Related Concussion (SRC) may increase subsequent injury risk (1–3), with disturbances to the neuromuscular control system often theorised as a contributing factor (4).  Outside elite sport, protocols advise 14-days physical rest and 5-days graded Return To Play (RTP). Despite a link between high acute-on-chronic workload ratios and increased injury risk (5), little attention has been given to the effect of no physical exercise for 14 days and RTP shortly after this.  This blog will go on to explore this further.

What may be causing the increased injury risk?

Neuromuscular control whilst performing complex tasks (often under fatigue) are qualities required for sporting activities. Impaired ability to perform these may increase injury risk (4),In particular, impaired neuromuscular control (6,7) has been associated with risk of cruciate ligament injury and deficient balance has been linked to ankle injury (8,9). Injury risk after SRC may be due to a variety of reasons:

  • Altered balance: slow or inappropriate response to perturbations from impaired proprioception, motor control, Vestibular-Ocular-Motor (VOM) function and reduced strength (10–15).
  • Poor movement patterns: altered processing of sensory feedback and feedforward mechanisms alter motor control, coordination, postural stability and agility (16,17). 
  • Slower reactions: altered integration and processing of stimuli and VOM dysfunction may alter anticipatory muscle activation and speed to react to others (18,19).  
  • Reduced strength: altered neural activity may reduce max strength and rate of force development, impairing movement efficiency (20,21).
  • Neurocognitive function: reaction time and motor processing speed deficits may impair decision-making, affecting neuromotor (22–28) and sensorimotor control (1).   
  • Dual task activities: reduced physical and/or cognitive performance (29,30) may negatively affect physical performance whilst making strategic decisions. 
  • Physical loading tolerance: returning to too much load too quickly has been linked to increased injury risk (5). 

Deficits have been reported up to 90 days post injury (11,31) and long after athletes have RTP (32,33).  Despite these factors, many graded RTP protocols do not suggest focusing on any of the above aspects during or after RTP, this could leave athletes unable to cope with the demands of their sport.  

How does this inform my practice?

Extending SRC rehabilitation beyond the standardised protocols may reduce subsequent injury risk.  Several assessments have been researched/studied, many detecting more than one dysfunction, and dysfunction of one system interacting and impairing function of another.  For example, dysfunction of the cervical spine may produce, or contribute to, VOM dysfunction, consequently altering balance and coordination (34).  Hence, clinicians should be aware treatment of a singular dysfunction may not resolve symptoms, and a multi-faceted approach to assessment and treatment is warranted (35–37).  The Post-Concussion Symptom Scale may help clinicians to select which assessments are higher priority, depending on what type of symptoms are reported (Figure 1).

Using a symptom-based approach to assessment, clinicians can start a targeted approach to rehabilitation and monitoring after RTP, depending on what dysfunctions are present.  For example;

  • Vestibular and cervical rehabilitation has been shown to improve VOM dysfunction (34).
  • Exercise intolerance can be treated with a graded increment of aerobic exercise (38).
  • Dual task exercises may restore motor control, postural stability and ability to complete dual task activities (4).
  • Strengthening neck and global muscle groups may reduce injury risk when returning to sport (39).
  • Returning athletes to adequate loading prior to RTP will ensure the load is adequate to meet the demands of their sport.


  • SRC increases subsequent injury risk through a variety of mechanisms.
  • Motor control, spatial awareness, dual task activities, and reaction times may be affected long after athletes have RTP.
  • A multi-faceted approach to assessment and rehabilitation during and following RTP may reduce injury risk.

Take home messages:

Authors and Affiliations

Kerry Glendona*, Glen Blenkinsopa, Antonio Bellib, and Matthew Paina

aSchool of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK; 

b Institute of Inflammation and Ageing, University of Birmingham, UK

*Physios in Sport Association: supports Chartered Physiotherapists who are interested in and or work in Sports & Exercise Medicine.  Please follow this link to find out more information about their upcoming Golden Jubilee event on 1st July, which is open to all professions.

Authors have no competing interests. 


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