Concussion Management and Treatment
Exercise therapy is recommended as an appropriate intervention for adolescents with acute concussion after an initial 24-48 hours of relative rest, while strict bed rest should be avoided. 1
Initial Management (First 24-48 Hours)
- Implement a period of relative rest for 24-48 hours after concussion diagnosis 1
- Avoid strict bed rest and high-intensity physical activity 1
- Use acetaminophen as the preferred medication for headache management 2, 1
- Avoid medications except acetaminophen unless specifically recommended by a physician 2
- Instruct patients to avoid alcohol, illicit drugs, and other substances that might interfere with cognitive function and recovery 2
Medication Management
- First-line treatment for post-concussion headaches:
- Monitor for analgesic overuse which can lead to rebound headaches 1
- Avoid opioids due to high risk of dependency and rebound headaches 1
Progressive Return to Activity Protocol
After the initial 24-48 hours of relative rest, implement a 5-stage graded return to activity protocol:
| Stage | Activity | Duration |
|---|---|---|
| 1 | Symptom-limited activity | ≥24 hours |
| 2 | Light aerobic exercise | ≥24 hours |
| 3 | Sport-specific exercise | ≥24 hours |
| 4 | Non-contact training drills | ≥24 hours |
| 5 | Full-contact practice | ≥24 hours |
- Each stage should last a minimum of 24 hours 1
- Progress to next stage only if asymptomatic at current stage 1
- If symptoms develop, scale back exertion level to allow maximal activity without triggering symptoms 2
Management of Persistent Symptoms (>10 days)
For patients with persistent symptoms beyond 10 days, implement targeted interventions:
- Graded physical exercise program at a level that does not exacerbate symptoms 1, 3
- Vestibular rehabilitation for patients with vestibular symptoms 1, 3
- Manual therapy for patients with cervical spine involvement 1, 3
- Psychological treatment for anxiety/mood symptoms 1
- Vision therapy for ocular-motor issues 1
- Cognitive rehabilitation for persistent cognitive deficits 1
Special Considerations
- Assessment: Evaluate all five concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) 1
- Return to play: No same-day return to play for diagnosed concussions 1
- Medical clearance: Required from a licensed healthcare provider trained in concussion management before full return to play 1
- Warning signs: Instruct patients/families to seek immediate medical attention if symptoms worsen (worsening headache, repeated vomiting, increasing confusion) 1
Common Pitfalls to Avoid
- Prolonged complete rest: Evidence suggests that prolonged activity restriction may contribute to protracted recovery and other complications 4
- Premature return to high-risk activities: Returning to full contact activities before completing the graded protocol increases risk of re-injury
- Overmedication: Avoid prescribing medications beyond acetaminophen without physician guidance 2
- Ignoring psychological factors: Psychological consequences of removal from validating life activities can contribute to persistent symptoms 4
- Overlooking coexistent pathologies: Symptoms are not specific to concussion and it's important to consider and manage other potential causes 3
The most current evidence supports a balanced approach of brief relative rest followed by gradual, controlled reintroduction of activity that stays below the symptom threshold, rather than prolonged complete rest or premature return to full activity.