Post-Concussion Syndrome Management Guidelines
The management of post-concussion syndrome requires a structured approach beginning with 24-48 hours of complete physical and cognitive rest, followed by a gradual, stepwise return to activities with each step taking at least 24 hours and requiring the patient to be asymptomatic before progressing. 1, 2
Initial Management (First 24-48 Hours)
- Complete physical rest is essential during the first 24-48 hours after concussion 1
- Cognitive rest should be implemented, limiting activities requiring concentration such as reading, video games, computer use, television, and exposure to loud music or bright lights 2
- No return to play should occur on the same day of injury ("When in doubt, sit them out!") 1
- Avoid all medications except acetaminophen as recommended by a physician 1, 2
Warning Signs Requiring Immediate Medical Attention
- Loss of consciousness, severe or worsening headache, repeated vomiting 1
- Altered mental status, seizures, visual changes 1
- Focal neurologic deficits, abnormal behavior, increased sleepiness 2
- Swelling or deformities of the scalp 1
Structured Return to Activity Protocol
- After the initial 24-48 hour rest period, implement a stepwise return to activity protocol 1, 2
- Each step must take a minimum of 24 hours 3
- If symptoms recur during any step, return to the previous asymptomatic level and try to progress again after 24 hours of rest 3, 1
Graded Return to Activity Steps:
- No activity (complete rest)
- Light aerobic exercise (walking, swimming, stationary cycling)
- Sport-specific training (running drills in sports)
- Non-contact training drills
- Full contact practice (after medical clearance)
- Return to normal activity/play 2
Academic Accommodations
- Temporary academic accommodations should include: 1
- Shortened school days
- Reduced workloads
- Extended time for assignments and tests
- Postponement of standardized testing
Management of Persistent Symptoms (>10 days)
- Symptoms persisting beyond 10 days require multidisciplinary management 3, 1
- Neuropsychological testing can assist in identifying specific cognitive deficits and guiding return to activity decisions 1
- Consider the following interventions for persistent symptoms:
- Graded physical exercise (gradually increasing intensity over time, at least once weekly for 4 weeks) 2, 4
- Vestibular rehabilitation for balance issues (including habituation exercises, adaptation exercises, and balance training) 2
- Manual therapy for neck and spine when neck pain is present 2
- Cognitive rehabilitation for ongoing cognitive deficits 4
- Cognitive behavioral therapy for psychological symptoms 4
Medication Management
- Do not return to play while taking any medications for concussion symptoms 3, 1
- Medication should be used cautiously and only as directed by a physician 1, 2
Common Pitfalls to Avoid
- Returning to activity too soon before symptoms have resolved 1, 2
- Inadequate rest during the initial 24-48 hours 1
- Ignoring symptoms or lack of proper medical evaluation 1, 2
- Strict rest beyond 48 hours, which can be detrimental to recovery 2, 5, 6
- Relying solely on patient-reported symptoms without objective assessment 1
Long-term Monitoring
- Monitor for chronic headaches, dizziness, balance problems, vision problems, sensitivity to noise/light 2
- Watch for depression, mood swings, memory problems, difficulty concentrating 2
- Sleep difficulties and persistent fatigue should be addressed 1, 2
- Repeated concussions may lead to long-term difficulties with memory, concentration, and other neurological issues 1
- Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 1
Special Considerations
- Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 1
- Maintain consistent sleep-wake cycles to support recovery 1
- Approximately 10-20% of concussion patients develop persistent symptoms requiring more intensive intervention 4, 7