Concussion Treatment
For adolescents with acute concussion, exercise therapy is the recommended treatment, while strict rest beyond 24-48 hours should be avoided as it can worsen outcomes. 1
Initial Management (First 24-48 Hours)
Implement moderate physical and cognitive rest for only the first 24-48 hours after injury. 2, 3 This brief rest period allows for initial recovery during the acute neurometabolic cascade. 4
Immediate Actions:
- Remove the individual from play immediately if concussion is suspected—"When in doubt, sit them out!" 2, 3
- Monitor for warning signs requiring emergency evaluation: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or focal neurologic deficits 2, 4
- Limit medications to acetaminophen only, and only as recommended by a physician 2, 3
Critical Pitfall to Avoid:
Do not prescribe strict rest beyond 3 days—prolonged rest is detrimental and can actually worsen outcomes, prolong recovery, cause physical deconditioning, and contribute to reactive depression. 1, 2, 5, 6
Post-Acute Management (After 24-48 Hours)
Exercise Therapy for Adolescents:
Begin graded exercise therapy after the initial 24-48 hour rest period for adolescent patients. 1 The 2023 PM&R consensus panel found sufficient evidence to recommend exercise as appropriate therapy specifically for adolescents with acute concussion. 1
- Start with supervised, non-contact aerobic exercise below the symptom-exacerbation threshold 2, 6
- Gradually increase intensity and complexity over time 4
- Each progression step should take a minimum of 24 hours 2, 3
- If symptoms recur, return to the previous asymptomatic level and retry progression after 24 hours of rest 2, 3
Stepwise Return to Activity Protocol:
- Light aerobic exercise (walking, swimming, stationary cycling) 2
- Sport-specific exercise (skating drills, running drills) 2
- Non-contact training drills (passing drills, resistance training) 2
- Full-contact practice (only after medical clearance) 2
- Return to competition 2
Important: Avoid high-intensity physical activity during recovery as this is detrimental. 1, 2
Return to School/Cognitive Activities
Gradually increase duration and intensity of academic activities as tolerated after the initial 24-48 hour rest period. 2, 3
Temporary Accommodations (if needed):
- Shortened school days 2, 3
- Reduced workloads 2, 3
- Extended time for assignments and tests 2, 3
- Postponement of standardized testing 3, 4
Management of Persistent Symptoms (Beyond 10 Days)
For symptoms persisting beyond 10 days, implement multidisciplinary management. 2, 3 Note that 15-20% of concussion patients develop persistent post-concussion syndrome. 2, 3
Evidence-Based Interventions for Persistent Symptoms:
- Graded physical exercise performed at least weekly for minimum 4 weeks, below symptom exacerbation threshold 4
- Vestibular rehabilitation for persistent vestibular dysfunction (habituation exercises, adaptation exercises, balance training) 4
- Manual therapy for neck and spine, especially when neck pain is present 4
- Psychological treatment as part of multidisciplinary approach 2
- Formal neuropsychological assessment for persistent cognitive symptoms 2, 3
Age-Specific Considerations
Younger athletes require more conservative management with stricter return-to-play guidelines as recovery takes longer compared to older athletes. 2, 3
Evidence Quality Note
The 2023 PM&R consensus statement (the most recent and highest quality guideline) reviewed 6,303 articles and found strong evidence only for exercise therapy in adolescents with acute concussion. 1 For other age groups and interventions, the evidence remains limited to small randomized controlled trials and observational studies of moderate to low quality. 1 However, most interventions are safe when used judiciously and tailored to individual patient needs. 1
Return to Play Criteria
Allow return to full activity only when the patient: