Concussion Management Protocol
The recommended protocol for managing a concussion includes immediate removal from activity, 24-48 hours of relative rest, followed by a structured 5-stage graded return to activity protocol, with each stage lasting at least 24 hours and progression contingent on remaining symptom-free. 1
Initial Management (First 24-48 Hours)
- Immediately remove the person from activity when concussion is suspected
- Conduct a comprehensive assessment evaluating all five concussion subtypes:
- Cognitive
- Ocular-motor
- Headache/migraine
- Vestibular
- Anxiety/mood 1
- Implement relative rest (not complete bed rest) for 24-48 hours 1, 2
- Avoid high-intensity physical activity during this period 1
- Use acetaminophen as the preferred medication for headache management 1
- Avoid medications except acetaminophen unless specifically recommended by a physician 1
Graded Return to Activity Protocol
After the initial 24-48 hour rest period, follow this 5-stage 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 |
- Progress to the next stage only if asymptomatic at the current stage 1
- If symptoms return during any stage, stop activity immediately, rest for at least 24 hours, and resume at the previous asymptomatic level 1
- The minimum recovery time is 5 days to progress through the protocol 1
Medication Management
- For headaches: Use acetaminophen (1000 mg) as first-line treatment 1
- Alternative: Ibuprofen (400 mg) may be used 1
- Monitor for analgesic overuse that can lead to rebound headaches 1
- Avoid alcohol, illicit drugs, and substances that might interfere with cognitive function 1
Return to School/Work Considerations
- School performance may be significantly affected in children with concussion 1
- Implement gradual return to cognitive activities as tolerated 1, 2
- Avoid prolonged cognitive rest as it can be detrimental to recovery 2, 3
- Exercise is recommended as appropriate therapy after 24-48 hours of relative rest 1
Special Considerations
- Loss of consciousness occurs in less than 10% of concussions but may indicate more significant injury if present for more than 30 seconds 1
- Athletes experiencing loss of consciousness or amnesia should be disqualified from further participation on the day of injury 1
- Treat individuals with a history of concussion more conservatively 1
- Consider temporary or permanent disqualification from contact sports for those with three or more concussions and slowed recovery 1
Management of Persistent Symptoms
For post-concussion syndrome, implement targeted interventions:
- Graded physical exercise
- Vestibular rehabilitation
- Manual therapy
- Psychological treatment
- Vision therapy
- Cognitive rehabilitation 1
Follow-up and Return to Play
- Require medical clearance from a licensed healthcare provider trained in concussion management before full return to play 1
- Provide clear discharge instructions about warning signs and when to seek emergency care 1
- Consider referral to a concussion specialist for complex cases or persistent symptoms 1
Common Pitfalls to Avoid
- Prolonged complete rest: Research shows that prolonged cognitive and physical rest can be detrimental to recovery 2, 3, 4
- Returning to activity too soon: Returning before symptoms resolve increases risk of prolonged recovery and second-impact syndrome 1
- Inadequate follow-up: Failing to monitor symptom progression can lead to missed complications 1
- Overlooking the importance of immediate intervention: Starting cognitive and physical rest immediately after injury leads to faster recovery compared to delayed implementation 5