Concussion Management Guidelines
Immediate removal from activity and evaluation by a healthcare professional is the cornerstone of concussion management to prevent worsening outcomes and reduce risk of long-term complications. 1, 2
Initial Management (First 24-48 Hours)
- Implement moderate physical and cognitive rest for the first 24-48 hours after concussion to allow initial recovery 1, 3
- Remove the individual from play/activity immediately if concussion is suspected - "When in doubt, sit them out!" 1, 3
- Never allow return to play on the same day of injury 1
- Monitor for warning signs requiring immediate medical attention: loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, swelling or deformities of the scalp 2, 1
- Avoid medications except acetaminophen, and only as recommended by a physician 1, 3
After Initial 24-48 Hours
- Avoid strict prolonged rest (exceeding 3 days) as this can worsen outcomes 1, 4, 5
- Begin gradual reintroduction of activities that do not worsen symptoms 1, 6
- Implement a progressive schedule with close monitoring of symptom expression 1
- Introduce supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold 1, 7
Return to School/Cognitive Activities
- Gradually increase duration and intensity of academic activities as tolerated 1, 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 with each step taking a minimum of 24 hours 1, 6:
- If symptoms recur during the protocol, return to the previous asymptomatic level and try to progress again after 24 hours of rest 1, 3
- Do not return to play while taking any medications for concussion symptoms 1, 3
- Allow return to full activity only when the individual has returned to premorbid performance and remains symptom-free 1
Management of Persistent Symptoms
- Implement multidisciplinary management for symptoms persisting beyond 10 days 1, 3
- Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 1, 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 1, 8
Special Considerations
- Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 1, 3
- Older patients often experience concussions from low-velocity mechanisms such as falls from standing height 1, 8
- Geriatric patients require lower thresholds for trauma protocol activation and comprehensive frailty assessment 8
Common Pitfalls to Avoid
- Returning to activity too soon, which can worsen outcomes or prolong recovery 1, 3
- Inadequate rest during the acute phase (first 24-48 hours) 1
- Excessive rest beyond the initial 24-48 hours, which can be counterproductive 1, 4, 5
- Relying solely on patient-reported symptoms without objective assessment 1
- Inconsistent online resources that may provide conflicting information about concussion management 2
Evidence Quality Considerations
- Online resources often lack clarity and do not consistently follow published guideline recommendations 2
- Most concussion management studies have limitations including small sample sizes, variable timeframes of intervention, and lack of control groups 2
- The lack of an objective clinical standard for defining and diagnosing concussion limits the ability to generate a standardized clinical practice guideline 2