What are the guidelines for managing a concussion?

Concussion Management Guidelines

Immediate Post-Injury Management

Any athlete with a suspected or diagnosed concussion must be immediately removed from play and not allowed to return to activity on the same day of injury under any circumstances. 1, 2, 3

Initial Rest Period (First 24-48 Hours)

• Complete physical and cognitive rest for 24-48 hours is essential to allow the brain to recover during the acute neurometabolic cascade when energy deficit and vulnerability are highest. 4, 2, 3
• Avoid activities requiring concentration, including schoolwork, video games, computer use, television, and loud music during this initial period. 3
• Resume normal activities of daily living as tolerated, but avoid activities that trigger or worsen symptoms. 1
• Do not prescribe complete bed rest, as this is not recommended and may be counterproductive. 1

Medication Guidelines

• Only acetaminophen should be used for symptom management immediately after injury, and only as recommended by a physician. 1, 2
• Avoid all other medications including NSAIDs, aspirin (theoretical bleeding risk), alcohol, and illicit drugs that might interfere with cognitive function and neurological recovery. 1
• Never allow return to play while taking any medications for concussion symptoms, as this indicates incomplete recovery. 1, 2, 3

Warning Signs Requiring Emergency Medical Attention

Activate emergency medical services immediately if any of the following occur: 1, 4, 2

• Loss of consciousness
• Severe or worsening headache
• Repeated vomiting
• Altered mental status or confusion
• Seizures
• Visual changes
• Focal neurological deficits
• Swelling or deformities of the scalp
• Increased sleepiness or difficulty arousing

Graded Return-to-Activity Protocol

After the initial 24-48 hour rest period, begin a structured stepwise progression rather than continuing prolonged complete rest, which may actually worsen outcomes. 2, 5, 6

Five-Step Progression Protocol

Each step must take a minimum of 24 hours before advancing to the next level: 1, 4, 2

1. Light aerobic exercise - Walking, swimming, or stationary cycling at <70% maximum heart rate; no resistance training. 2, 7
2. Sport-specific exercise - Skating drills in hockey, running drills in soccer; no head impact activities. 2, 7
3. Non-contact training drills - Progression to more complex training drills; may start progressive resistance training. 2, 7
4. Full-contact practice - Following medical clearance, participate in normal training activities. 2, 7
5. Return to competition - Normal game play. 2, 7

Critical Protocol Rules

• If any symptoms recur at any step, immediately stop activity, rest for 24 hours, then return to the previous asymptomatic level before attempting to progress again. 1, 4, 2
• Exercise should be performed below the symptom exacerbation threshold and gradually increased in intensity. 2, 8
• Supervised, non-contact aerobic exercise below symptom threshold is particularly beneficial for adolescents with acute concussion. 3, 6

Academic Accommodations

Students require cognitive rest and temporary academic accommodations while recovering: 4, 2, 7

• Shortened school days
• Reduced workloads
• Extended time for assignments and tests
• Postponement of standardized testing
• Gradual increases in duration and intensity as tolerated

Management of Persistent Symptoms (Beyond 10 Days)

Symptoms persisting beyond 10 days require multidisciplinary management, as 15-20% of patients develop persisting symptoms. 1, 4, 3

Evidence-Based Interventions for Persistent Symptoms

• Graded physical exercise below symptom threshold as a primary intervention. 3, 8
• Vestibular rehabilitation specifically for persistent vestibular dysfunction (not vestibular suppressant medications like meclizine). 3
• Cervical spine manual therapy for patients with persistent neck pain and dizziness. 3, 8
• Vision therapy for oculomotor dysfunction. 3
• Cognitive behavioral therapy for psychological symptoms. 3
• Formal neuropsychological assessment to identify specific cognitive deficits and guide treatment. 4, 7
• Referral to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks. 3

What NOT to Use

Vestibular suppressants like meclizine, antihistamines, and benzodiazepines should not be routinely used to treat concussion symptoms, as they show no benefit as definitive primary treatment, may interfere with central compensation mechanisms critical for recovery, and can decrease diagnostic sensitivity during clinical examination. 3

Special Considerations for Younger Athletes

Youth athletes (under 18 years) must be managed more conservatively with stricter return-to-play guidelines because: 1, 4

• Damage to the maturing brain can be catastrophic
• Almost all reported cases of second-impact syndrome occur in young athletes
• Recovery generally takes longer in younger athletes compared to older ones
• The developing brain is more vulnerable to prolonged dysfunction

Role of Neuropsychological Testing

• Neuropsychological testing can assist in identifying specific cognitive deficits and guiding return-to-activity decisions, but should only be used as part of a comprehensive concussion management strategy, not in isolation. 1, 4, 7
• Computerized neuropsychological testing should be interpreted by healthcare professionals trained and familiar with the specific test and its limitations. 7
• Most concussions can be managed appropriately without neuropsychological testing. 7
• Comprehensive neuropsychological evaluation is helpful for athletes with persistent symptoms or complicated courses. 7

Critical Pitfalls to Avoid

The most common and dangerous errors in concussion management are: 4, 2

1. Returning to activity too soon - This significantly worsens outcomes, prolongs recovery, and increases risk of repeat concussion or catastrophic injury.
2. Inadequate rest during the acute 24-48 hour phase - This compromises initial recovery during the critical neurometabolic cascade.
3. Prolonged complete rest beyond 3 days - This can actually worsen outcomes and be detrimental to recovery. 3, 5
4. Ignoring symptoms or avoiding proper medical evaluation - This delays appropriate care and increases risk.
5. Relying solely on patient-reported symptoms without objective assessment - Athletes may underreport symptoms to return to play sooner. 4
6. Allowing return to play while taking symptom-management medications - This masks incomplete recovery. 1, 2

Long-Term Considerations

• Repeated concussions may lead to long-term difficulties with memory, concentration, chronic fatigue, persistent headaches, depression, and other neurological sequelae. 1, 2, 7
• A history of concussion is associated with higher risk of sustaining another concussion. 7
• Greater number, severity, and duration of symptoms after a concussion predict prolonged recovery. 7
• There is increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae, though large-scale epidemiological studies are needed to more clearly define risk factors. 7