What are the guidelines for patient education and management following a concussion?

Patient Education for Concussion

Patients and families must understand that no return to play should occur on the day of injury, and an initial 24-48 hour period of complete physical and cognitive rest is essential before beginning a gradual, stepwise return to activities. 1, 2

Critical Initial Instructions

Immediate Rest Period (First 24-48 Hours)

• Complete physical rest for the first 24-48 hours after injury is mandatory 2
• Cognitive rest is equally essential during this early phase, limiting all activities requiring concentration including screen time, reading, homework, and texting 2
• Patients who implement immediate cognitive and physical rest recover 4.6 days sooner than those who delay rest, with 67% recovering within 30 days compared to only 35% with delayed rest 3
• "When in doubt, sit them out!" should guide all initial decisions 2

Absolute Contraindications

• Never return to play on the same day of injury - this is universally agreed upon to prevent additional head impacts, delayed symptom resolution, and rarely, second-impact syndrome 1
• Do not return to play while taking any medications for concussion symptoms 1, 2

Warning Signs Requiring Immediate Emergency Care

Educate patients to seek immediate medical attention for: 2

• Loss of consciousness
• Severe or worsening headache
• Repeated vomiting
• Altered mental status or confusion
• Seizures
• Visual changes
• Swelling or deformities of the scalp

Graded Return-to-Activity Protocol

Starting the Protocol

• Begin only after the initial 24-48 hour rest period and when asymptomatic at rest 2
• Each step must take a minimum of 24 hours 1, 2
• If any symptoms recur at any step, immediately return to the previous asymptomatic level and rest for 24 hours before attempting to progress again 1, 2

Academic Accommodations

Temporary school modifications should include: 2

• Shortened school days
• Reduced workloads
• Extended time for assignments and tests
• Postponement of standardized testing
• These accommodations should continue until cognitive symptoms resolve

Medication Guidelines

• Avoid all medications except acetaminophen immediately after injury, and only as recommended by a physician 2
• Patients must not mask symptoms with medication to enable premature return to activities 1, 2

Timeline Expectations and Red Flags

Typical Recovery

• More than 80% of athletes with concussion return to play within 1 month of symptom onset 1
• Recovery may take longer in younger athletes compared to older ones 2

Persistent Symptoms (>10 Days)

• Symptoms persisting beyond 10 days require multidisciplinary management involving coordination between multiple healthcare disciplines 1, 2
• Approximately 15-20% of concussion patients develop persistent symptoms requiring more intensive intervention 2, 4
• Formal neuropsychological assessment should be considered for patients with persistent cognitive symptoms 2

Critical Pitfalls to Avoid

Most Common Mistakes

• Returning to activity too soon - this is the single most important error that worsens outcomes and prolongs recovery 2
• Inadequate rest during the acute 24-48 hour phase 2
• Ignoring symptoms or attempting to "push through" 2
• Lack of proper medical evaluation before return to play 2
• Relying solely on patient-reported symptoms without objective assessment 2

The Danger of Prolonged Complete Rest

• While initial rest (24-48 hours) is beneficial, complete rest exceeding 3 days is probably not helpful and prolonged avoidance of all activity can be detrimental 5, 6, 7, 8
• After the initial rest period, gradual resumption of activities should begin as tolerated 6, 7

Long-Term Considerations

• Repeated concussions may lead to long-term difficulties with memory, concentration, fatigue, headache, and other neurological issues 2
• Each subsequent concussion should be managed more conservatively with stricter return-to-play guidelines 2
• Patients should maintain consistent sleep-wake cycles throughout recovery to support healing 2

Communication with Healthcare Providers

• Patients and families should communicate all symptoms to an athletic trainer or physician rather than relying on online resources, which are inconsistent and often contradict published guidelines 1
• Neuropsychological testing can assist in identifying specific cognitive deficits and guiding return-to-activity decisions 1, 2