Concussion Treatment Protocol
The recommended treatment for concussion involves 24-48 hours of relative rest followed by a gradual return to activity using a structured 5-stage protocol, with each stage lasting at least 24 hours and progressing only if the patient remains symptom-free. 1
Initial Management (First 48 Hours)
- Relative rest for 24-48 hours (not complete bed rest) 1, 2, 3
- Avoid high-intensity physical and cognitive activities 1
- Use acetaminophen as first-line treatment for headache management 1
- Avoid medications except acetaminophen unless specifically recommended by a physician 1
- Avoid alcohol, illicit drugs, and substances that interfere with cognitive function 1
Graded Return to Activity Protocol
After the initial rest period, implement this 5-stage protocol, with each stage lasting at least 24 hours 1:
- Stage 1: Symptom-limited activity (daily activities that don't provoke symptoms)
- Stage 2: Light aerobic exercise (walking, swimming, stationary cycling)
- Stage 3: Sport-specific exercise (running drills, no head impact)
- Stage 4: Non-contact training drills (more complex training)
- Stage 5: Full-contact practice (following medical clearance)
Important: If symptoms return during any stage, stop activity immediately, rest for at least 24 hours, and resume at the previous asymptomatic level 1
Medication Management
- First-line for headaches: Acetaminophen (1000 mg) 1
- Alternative: Ibuprofen (400 mg) may be used 1
- Caution: Monitor for analgesic overuse that can lead to rebound headaches 1
Special Considerations
For Athletes
- Athletes who are symptomatic at rest or after exertion for at least 20 minutes should not return on the day of injury 1
- Those experiencing loss of consciousness or amnesia should be disqualified from further participation on the day of injury 1
- Athletes with three or more concussions and slowed recovery may need temporary or permanent disqualification from contact sports 1
For Persistent Symptoms (Post-Concussion Syndrome)
Targeted interventions may include 1, 4:
- Graded physical exercise
- Vestibular rehabilitation
- Manual therapy
- Vision therapy
- Cognitive rehabilitation
Evidence Quality and Considerations
Recent evidence strongly supports early, controlled physical activity rather than prolonged rest. A meta-analysis of seven studies showed that physical activity and prescribed exercise improved recovery by a mean of 4.64 days 4. This represents a significant shift from older recommendations of complete rest until symptom resolution.
Common Pitfalls to Avoid
- Prolonged complete rest can be detrimental to recovery 2, 3, 4
- Returning to play too soon before symptoms resolve increases risk of second-impact syndrome 1
- Ignoring sleep disturbances which are associated with slower recovery 4
- Overuse of analgesics can lead to rebound headaches 1
- Screen use in the first 48 hours may delay recovery 4
Follow-up and Return to Play
- Require medical clearance from a licensed healthcare provider trained in concussion management before full return to play 1
- The minimum recovery time is 5 days to progress through the protocol, provided symptoms do not return 1
- Consider referral to a concussion specialist for complex cases or persistent symptoms 1