What is the recommended treatment for a concussion?

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 worsens outcomes. 1, 2

Initial Management (First 24-48 Hours)

Implement moderate physical and cognitive rest for only the first 24-48 hours after injury. 2, 3, 4 This brief rest period allows initial recovery during the acute neurometabolic cascade when the brain has increased energy demands with decreased cerebral blood flow. 4

What "Moderate Rest" Means:

• Temporary reduction in school workload 4
• Avoidance of video games, computer use, television, and loud music 4
• Limited physical activity 2
• Light mental activity is permitted 5

Critical Pitfall to Avoid:

Do not prescribe strict prolonged rest exceeding 3 days—this is detrimental and delays recovery. 1, 2, 3 Prolonged activity restriction contributes to physical deconditioning and psychological consequences that worsen postconcussive symptoms. 6

Immediate Actions:

• Remove from play immediately if concussion is suspected 2, 4
• Monitor for red flags requiring emergency imaging: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, focal neurologic deficits 2, 3

Symptom Management:

• Acetaminophen 650-1000 mg every 4-6 hours for headache 3
• Warn patients explicitly: taking pain medication more than 2-3 days per week causes rebound headaches that worsen the condition 3
• Avoid NSAIDs/aspirin in the acute phase due to theoretical bleeding risk 4

Active Recovery Phase (After 48 Hours)

Begin gradual reintroduction of activities that do not worsen symptoms after the initial 24-48 hour rest period. 2, 7, 5

Exercise as Primary Therapy:

For adolescents specifically, supervised sub-threshold aerobic exercise is an evidence-based therapeutic intervention. 1 This represents the strongest recommendation from the 2023 PM&R consensus statement based on systematic review of 80 studies. 1

Sub-Threshold Exercise Protocol:

• Begin with light aerobic exercise below the symptom exacerbation threshold 2, 3, 4
• Activities include walking, swimming, or stationary cycling 2
• Avoid high-intensity physical activity during recovery as this is detrimental 1, 3, 4
• Monitor symptom expression (number and severity) closely 2

Stepwise Return to Activity Protocol

Follow a structured progression with each step taking a minimum of 24 hours before advancing. 2, 4

The Six-Step Protocol:

1. Light aerobic exercise (walking, swimming, stationary cycling) 2, 4
2. Sport-specific exercise (skating drills in hockey, running drills in soccer) 2, 4
3. Non-contact training drills (passing drills, resistance training) 2, 4
4. Full-contact practice (following medical clearance) 2, 4
5. Return to competition 2, 4

Progression Rules:

• If symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again 2, 4
• Each step requires minimum 24 hours before advancing 2, 4
• Do not return to play while taking any medications for concussion symptoms—this indicates incomplete recovery 2, 4

Return to School/Cognitive Activities:

• Gradually increase duration and intensity of academic activities as tolerated 2
• Implement temporary accommodations: shortened school days, reduced workloads, extended time for assignments and tests 2

Management of Persistent Symptoms (Beyond 10 Days)

Implement multidisciplinary management for symptoms persisting beyond 10 days. 2, 4 Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome. 2, 4

Multidisciplinary Treatment Options:

• Graded physical exercise below symptom threshold 4
• Vestibular rehabilitation for persistent vestibular dysfunction 3, 4
• Manual therapy for cervical spine and neck pain 3, 4
• Psychological treatment including cognitive behavioral therapy 3, 4
• Oculomotor vision therapy 4
• Consider tricyclic antidepressants (amitriptyline) for chronic headache management 3

When to Refer:

Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks. 3, 4

Evidence Quality and Nuances

The 2023 PM&R consensus statement represents the most comprehensive and recent guideline, systematically reviewing 6,303 articles with 80 meeting inclusion criteria. 1 The panel found sufficient evidence to recommend exercise specifically for adolescents with acute concussion, but acknowledged that evidence for other age groups and therapeutic modalities remains limited to moderate-to-low quality studies. 1

Important limitation: Most studies recruited from specialty concussion clinics, suggesting selection bias toward more severe cases. 1 This means the evidence may not fully represent asymptomatic patients who could still have residual cognitive and functional deficits. 1

What NOT to Do

Medications to Avoid:

Do not routinely use vestibular suppressants like meclizine or benzodiazepines—these show no benefit and may interfere with central compensation mechanisms critical for recovery. 4

Activity Restrictions to Avoid:

• Never allow same-day return to play after diagnosed concussion 4
• Do not prescribe complete cognitive rest 7, 5
• Avoid prolonged physical rest beyond the initial 48 hours 6, 5

Special Considerations:

• Manage younger athletes (<18 years) more conservatively with stricter return-to-play guidelines due to potential catastrophic effects on the maturing brain 4
• Recovery may take longer in younger athletes compared to older ones 2
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 2, 4