What is the best management approach for a 16-year-old boy with a concussion (mild traumatic brain injury) presenting with dizziness and headache after a football collision?

Management of Concussion in a 16-Year-Old Football Player

The best approach for managing this 16-year-old boy with concussion is to observe more restrictive physical and cognitive activity during the first 24-48 hours after injury, followed by a gradual schedule of activity that doesn't exacerbate symptoms, rather than strict bed rest until complete symptom resolution. 1, 2

Initial Management (First 24-48 Hours)

• Relative rest (both physical and cognitive) for the first 24-48 hours 1, 2
• Avoid activities that worsen symptoms
• Limit screen time during this initial period 3
• Acetaminophen can be used for headache management (preferred over NSAIDs in the acute phase) 2
• Monitor for warning signs of more serious injury:
  • Worsening headache
  • Repeated vomiting
  • Increased confusion
  • Seizures
  • Difficulty recognizing people or places

After Initial 24-48 Hours

Physical Activity Progression

1. Begin light aerobic exercise that doesn't exacerbate symptoms (e.g., walking)
2. Gradually increase intensity and duration as tolerated
3. Progress through a 5-stage return-to-play protocol, with each stage lasting at least 24 hours:
   • Stage 1: Symptom-limited activity
   • Stage 2: Light aerobic exercise
   • Stage 3: Sport-specific exercise
   • Stage 4: Non-contact training drills
   • Stage 5: Full-contact practice (only after medical clearance)

Cognitive Activity/Return to School

• Return to school with appropriate accommodations before returning to full sports participation 4
• Gradually increase cognitive demands:
  • Start with short periods of cognitive activity
  • Take frequent breaks
  • Gradually extend duration as tolerated
• Reduce workload and allow extra time for assignments
• Avoid standardized testing during recovery period

Screen Time Management

• Moderate screen time rather than complete elimination 3
• Both very low and very high screen time are associated with worse symptoms in the first 30 days post-injury 3
• Limit screen time that exacerbates symptoms (e.g., if light sensitivity is present)

Important Considerations

• Recovery is typically longer in adolescents than in college/professional athletes (7-10 days or longer) 1
• The minimum recovery time is 5 days to progress through the return-to-play protocol, provided symptoms don't return 2
• Medical clearance from a healthcare provider trained in concussion management is required before full return to play 2
• Monitor for post-concussion syndrome if symptoms persist beyond 4-6 weeks 1

Common Pitfalls to Avoid

1. Returning to play too soon: Never return to play on the same day as the concussion, even if symptoms resolve 1
2. Complete bed rest: Strict bed rest is not recommended and may prolong recovery 2
3. Ignoring cognitive symptoms: School performance may be significantly affected and requires appropriate accommodations 1, 2
4. Inconsistent monitoring: Close monitoring of symptoms during activity progression is essential 1
5. Ignoring recurrent concussions: Athletes with multiple concussions should be treated more conservatively 2

The outdated approach of strict bed rest until complete symptom resolution has been replaced by a more active rehabilitation approach that carefully balances rest and gradual return to activities. This approach has been shown to optimize recovery while minimizing the risk of prolonged symptoms.