What are the recommended treatment protocols for concussion?

Concussion Treatment

For acute concussion, implement 24-48 hours of moderate physical and cognitive rest, then immediately begin a supervised, graded aerobic exercise program below symptom threshold—particularly for adolescents where this approach has the strongest evidence for improving outcomes. 1

Immediate Management (First 24-48 Hours)

Implement moderate rest during the acute neurometabolic cascade, not strict prolonged rest which is detrimental. 1, 2

• Remove immediately from play—"When in doubt, sit them out!" 1, 2
• Complete physical and cognitive rest for 24-48 hours only 1, 2, 3
• Cognitive rest includes temporary reduction in school workload, avoidance of video games, computer use, television, and loud music 1
• Use acetaminophen for symptom management; avoid NSAIDs/aspirin due to theoretical bleeding risk 1
• Monitor for red flags requiring immediate imaging: repeated vomiting, worsening headache, focal neurologic deficits, altered mental status, seizures 1

Critical pitfall: Strict rest beyond 3 days worsens outcomes and is detrimental to recovery. 1, 4 The randomized trials demonstrate that prolonged cognitive/physical rest has either negative results or detrimental effects. 4

Graded Return to Activity Protocol (After 48 Hours)

Begin supervised, sub-symptom threshold aerobic exercise immediately after the initial 24-48 hour rest period. 4, 1 This has the strongest evidence, particularly for adolescents with acute concussion. 4

The stepwise protocol includes: 1, 2

• Step 1: Light aerobic exercise (minimum 24 hours)
• Step 2: Sport-specific exercise (minimum 24 hours)
• Step 3: Non-contact training drills (minimum 24 hours)
• Step 4: Full-contact practice (minimum 24 hours)
• Step 5: Return to competition

If symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again. 1, 2, 3

Critical pitfall: Never allow same-day return to play after diagnosed concussion. 1 Do not return to play while taking medications for concussion symptoms as this indicates incomplete recovery. 1, 2

Return to School/Cognitive Activity

Implement temporary academic accommodations starting after the initial 24-48 hour rest period, gradually increasing cognitive load as tolerated. 2, 3

Accommodations include: 2, 3

• Shortened school days
• Reduced workloads
• Extended time for assignments and tests
• Postponement of standardized testing

Adjust supports on an ongoing basis until academic performance returns to pre-injury levels. 3

Management of Persistent Symptoms (Beyond 10 Days)

Implement multidisciplinary management for symptoms persisting beyond 10 days. 1, 2

Treatment modalities include: 1, 3

• Graded physical exercise: Performed at least once weekly for minimum 4 weeks, below symptom exacerbation threshold 3
• Vestibular rehabilitation: For persistent vestibular dysfunction, including habituation exercises, adaptation exercises, and balance training 1, 3
• Cervical physical therapy/manual therapy: Especially when neck pain is present 1, 3
• Vision therapy: For visual symptoms 1
• Cognitive behavioral therapy: For psychological symptoms 1

Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks. 1, 3

Evidence Quality and Nuances

The 2023 PM&R consensus statement found sufficient evidence to recommend exercise as appropriate therapy specifically for adolescents with acute concussion, based on two high-quality RCTs with low to moderate risk of bias. 4 However, for other age groups and therapeutic modalities, mixed results and study limitations prevented firm conclusions. 4

The evidence consistently shows that strict rest and high-intensity physical activity are detrimental. 4 Prospective comparative studies suggested physical activity was associated with improved outcomes compared to physical rest. 4

Critical Pitfalls to Avoid

• Never allow return to play on the same day of injury 1, 2
• Avoid prolonged rest exceeding 3 days—this worsens outcomes 1, 4
• Avoid high-intensity physical activity during recovery—this is detrimental 1, 4
• Do not rely solely on patient-reported symptoms without objective assessment 1, 2
• Be more conservative with younger athletes (<18 years) due to potential catastrophic effects on the maturing brain 1
• Never return to play while taking medications for concussion symptoms 1, 2