Traumatic Brain Injury

sec_arr Return to Activity

Return to Activity

The LEO Task Group recommends formal evaluation by a health care provider with expertise in TBI/concussion rehabilitation prior to return to unrestricted duty for all LEOs who have: 1) multiple symptoms on initial presentation; and/or 2) symptoms lasting longer than 2 weeks; and/or 3) been hospitalized for a traumatic brain injury or concussion before returning to training activities. This recommendation is based on the usual recovery trajectory after sports-related concussion (SRC) and the literature that demonstrates worse clinical outcomes in patients with multiple symptoms, prolonged symptoms and hospitalization. Most athletes report the following symptoms after a SRC: headache, difficulty concentrating, feeling slowed down, dizziness, nausea, fatigue, and feeling mentally “foggy.”5 Recovery is typically rapid, with most athletes reporting minimal symptoms by 2 weeks and almost all returning to play within 30 days.5,6,7,8,9

Health care providers with expertise in TBI rehabilitation include physical medicine and rehabilitation physicians and neurologists. Some sports medicine physicians as well as neurosurgeons may also have TBI rehabilitation expertise based on their clinical practice. Neuropsychology, neuro-ophthalmology, neuro-optometry, and vestibular therapy are established parts of a multi-disciplinary TBI rehabilitation program.

An initial period of 24-48 hours of both relative physical and cognitive rest is recommended before starting a graduated return-to-activity pathway. The LEO Task Group recommends following the same graduated return to physical training activities used in the return-to-play decisions after SRC (see Table 2). Each stage should be a minimum of 24 hours, but can be longer if needed. If symptoms worsen, the LEO must go back to the previous stage.10 Prior to starting the return-to-activity pathway, the LEO should have a clinical neurological assessment, including evaluation of mental status/cognition, oculomotor function, gross sensorimotor, coordination, gait, vestibular function, and balance.

Table 2. Graduated Return-to-Sport Pathway10






Symptom-limited activity

Daily activities that do not provoke symptoms.

Gradual reintroduction of work/school activities


Light aerobic exercise

Walking, stationary bike at slow to medium pace. No resistance training.

Increase heart rate


Sport-specific exercise

Running or skating drills. No head impact activities.

Add movement


Non-contact training drills

Harder training drills. May start resistance training.

Exercise, coordination, increased cognitive demands


Full contact practice

Normal training activities after medical clearance.

Restore confidence and assess function


Return to sport

Normal game play.


Formal exercise testing to assess impairment and speed recovery after concussion, in addition to return-to-play pathways, is also supported by the literature. Leddy et al, has developed an exercise testing guideline for a post-TBI exercise prescription, which is an individualized, graded, sub-symptom threshold aerobic exercise program using a modified cardiac Balke protocol.11,12 Both return-to-play pathways and formal exercise testing speak to the value of functional testing to evaluate TBI-related symptoms under physiological demands and may be more relevant in the return to unrestricted duty determination compared to non-function-based testing.