What precautions should be taken after a concussion?

Concussion Precautions: Essential Guidelines for Recovery

After a concussion, a person should be immediately removed from physical activity, undergo complete physical and cognitive rest for 24-48 hours, and then follow a gradual stepwise return to activities only after being evaluated by a healthcare professional. 1

Immediate Management

• Any person showing signs or symptoms of concussion should be immediately removed from activity (play/sports) and not allowed to return until evaluated by a healthcare professional 1
• For severe head injury symptoms (loss of consciousness, worsening headache, vomiting, altered mental status, seizures, visual changes, swelling), activate emergency medical services immediately 1
• The phrase "When in doubt, sit them out!" is paramount in concussion management 1
• Under no circumstances should pediatric or adolescent athletes with concussion return to play the same day of their concussion 1

Physical Rest Requirements

• Complete physical rest for the first 24-48 hours after concussion 1
• After this initial period, follow a structured stepwise return to physical activity only when asymptomatic at rest 1
• Athletes should be withheld from physical exertion until they are asymptomatic at rest to prevent prolonged recovery 1
• Avoid activities that cause pain or exacerbate symptoms 1

Cognitive Rest Requirements

• Cognitive rest is essential for recovery, especially in the first 24-48 hours 1
• Limit activities requiring concentration and attention, including:
  • Reading (even for leisure) 1
  • Playing video games 1
  • Using computers 1
  • Viewing television 1
  • Exposure to loud music or bright lights 1
• Consider temporary accommodations for school, including:
  • Temporary leave of absence 1
  • Shortened school days 1
  • Reduced workloads 1
  • Extended time for assignments and tests 1
  • Postponement of standardized testing 1

Stepwise Return to Activity Protocol

After being completely asymptomatic at rest and having normal neurological and cognitive evaluations, follow this stepwise process:

1. No activity, complete rest until asymptomatic 1
2. Light aerobic exercise (walking, stationary cycling) 1
3. Sport-specific training (running, skating) 1
4. Non-contact training drills 1
5. Full contact training after medical clearance 1
6. Return to normal game play 1

Important: Each step should take a minimum of 24 hours. If any symptoms recur, the patient should drop back to the previous asymptomatic level and try to progress again after 24 hours of rest 1

Medication Considerations

• Avoid medications except acetaminophen after injury, and only take as recommended by a physician 1
• Avoid alcohol, illicit drugs, or other substances that might interfere with cognitive function and neurological recovery 1
• Do not return to play while taking any medications for concussion symptoms 1

Special Considerations for Children and Adolescents

• Recovery may take longer in younger athletes compared to older ones 1, 2
• High school athletes self-report symptom recovery at approximately 15 days compared with 6 days in collegiate athletes 2
• Younger athletes (<18 years) should be managed more conservatively with stricter return-to-play guidelines 1
• Parents, coaches, and school staff should be educated about the symptoms and management of concussion 1

Warning Signs Requiring Immediate Medical Attention

• Loss of consciousness 1
• Severe or worsening headache 1
• Repeated vomiting 1
• Altered mental status 1
• Seizures 1
• Visual changes 1
• Swelling or deformities of the scalp 1

Common Pitfalls to Avoid

• Returning to play too soon: Never return to play on the same day as the concussion 1
• Inadequate rest: Failing to observe both physical and cognitive rest can prolong recovery 1
• Ignoring symptoms: Continuing activities despite symptoms can worsen outcomes 1
• Lack of medical evaluation: All concussions should be evaluated by a healthcare professional before return to activities 1
• Underestimating recovery time: Recovery varies between individuals and may take longer in younger athletes 1, 2

Long-term Monitoring

• Monitor for persistent symptoms beyond 10 days, which may require multidisciplinary management 1
• For persistent symptoms, consider graded physical exercise, vestibular rehabilitation, or manual therapy of the neck and spine under professional guidance 1
• Be aware that repeated concussions may lead to long-term difficulties with memory, concentration, fatigue, headache, and other neurological issues 1