What is the standard protocol for managing a concussion?

Concussion Management Protocol

Exercise is recommended as the most appropriate therapy for acute concussion in adolescents, while strict rest and high-intensity physical activity should be avoided as they can be detrimental to recovery. 1

Initial Management (First 24-48 Hours)

• Implement moderate physical and cognitive rest for the first 24-48 hours after concussion to allow initial recovery 2, 3
• Avoid strict prolonged rest (exceeding 3 days) as this can actually worsen outcomes 2, 4
• Remove the individual from play immediately if a concussion is suspected - "When in doubt, sit them out!" 3
• Monitor for warning signs requiring immediate medical attention: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes 5, 3

Gradual Return to Activity Phase

• After the initial 24-48 hour rest period, begin gradual reintroduction of activities that do not worsen symptoms 2, 6
• Implement a progressive schedule with close monitoring of symptom expression (number and severity) 2, 7
• Introduce supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold 2, 6
• Each step in the return to activity protocol should take a minimum of 24 hours 3
• If symptoms recur during the protocol, return to the previous asymptomatic level and try to progress again after 24 hours of rest 5, 3

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated 2, 3
• Implement appropriate educational accommodations if symptoms interfere with academic performance 3
• Temporary accommodations may include shortened school days, reduced workloads, extended time for assignments and tests 3

Return to Play/Sports Protocol

• Follow a stepwise return to play protocol that typically includes:
  1. Light aerobic exercise (walking, swimming, stationary cycling) 2, 3
  2. Sport-specific exercise (skating drills in hockey, running drills in soccer) 3
  3. Non-contact training drills (passing drills, resistance training) 3
  4. Full-contact practice (following medical clearance) 3
  5. Return to competition 3
• Do not return to play while taking any medications for concussion symptoms 3
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 2

Management of Persistent Symptoms (>10 days)

• Implement multidisciplinary management for symptoms persisting beyond 10 days 3
• Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 5, 3
• Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 3
• A multidisciplinary approach may include graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and oculomotor vision treatment 5

Special Considerations

• Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 3
• Older patients often experience concussions from low-velocity mechanisms such as falls from standing height 5
• Avoid high-intensity physical activity during recovery as this can be detrimental 2, 6
• Medication use should be limited to acetaminophen only, and only as recommended by a physician 5, 3

Common Pitfalls to Avoid

• Returning to activity too soon, which can worsen outcomes or prolong recovery 3, 6
• Inadequate rest during the acute phase (first 24-48 hours) 3, 6
• Excessive rest beyond the initial 24-48 hours, which can be counterproductive 2, 4
• Relying solely on patient-reported symptoms without objective assessment 3
• Inconsistent online resources that may provide conflicting information about concussion management 1