What advice should I give a patient with a mild concussion?

Management of Mild Concussion

Advise your patient to rest moderately for 24-48 hours, then begin a gradual, supervised return to physical and cognitive activities that stay below their symptom threshold—avoiding both strict prolonged rest beyond 3 days and high-intensity exercise during recovery. 1, 2

Initial 24-48 Hour Period

• Implement moderate physical and cognitive rest for the first 24-48 hours after injury to allow initial neurometabolic recovery 1, 2
• Monitor closely for warning signs requiring immediate emergency evaluation: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, or visual changes 2
• Explain that symptoms typically resolve spontaneously in most cases, but 15-20% may develop persistent symptoms 1, 2

Critical Pitfall: Avoid Prolonged Rest

Do not prescribe strict rest beyond 3 days—this is detrimental and worsens outcomes. 1 The 2023 PM&R consensus found evidence of harm from strict rest, and patients advised to rest more than 2 days were significantly less likely to have returned to work/school at 1-2 months post-injury 1, 3. Prolonged activity restriction can trigger an "activity restriction cascade" leading to physical deconditioning, social isolation, and worsening of postconcussive symptoms 4.

Gradual Return to Activity (After Initial 48 Hours)

• Begin progressive reintroduction of activities that do not exacerbate symptoms with close monitoring of symptom number and severity 1, 5
• Introduce supervised, sub-symptom threshold aerobic exercise (walking, stationary cycling, swimming) 1, 2, 5
• For adolescents specifically, exercise therapy has the strongest evidence as the only intervention with sufficient data to recommend for acute concussion 1, 5, 6
• Each progression step should take minimum 24 hours; if symptoms recur, return to the previous asymptomatic level for 24 hours before advancing 2

Return to Cognitive Activities/School

• Gradually increase academic workload duration and intensity as tolerated 1, 2, 5
• Implement temporary accommodations if needed: shortened school days, reduced workloads, extended time for assignments and tests 2
• Customize the pace based on symptom severity rather than arbitrary timelines 5

Stepwise Return to Sports Protocol

Follow this specific progression, with each step taking minimum 24 hours 2:

1. Light aerobic exercise (walking, swimming, stationary cycling—no resistance training) 2
2. Sport-specific exercise (skating drills, running drills—no head impact) 2
3. Non-contact training drills (passing drills, progressive resistance training) 2
4. Full-contact practice (after medical clearance only) 2
5. Return to competition 2

• Allow full return only when the patient has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 1, 2, 5
• Do not permit return to play while taking any medications for concussion symptoms 2

Management of Persistent Symptoms (Beyond 10 Days)

• Implement multidisciplinary management including graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and oculomotor vision treatment 2
• Consider formal neuropsychological assessment for persistent cognitive symptoms 2
• Recognize that 15-20% develop persistent post-concussion syndrome requiring specialized care 1, 2

Key Activities to Avoid

• Strict rest beyond the initial 48 hours (worsens outcomes) 1, 4, 3
• High-intensity physical activity during recovery (detrimental effect demonstrated) 1, 2, 5
• Premature return to contact sports while symptomatic (increases reinjury risk during vulnerable recovery period) 1
• Relying solely on patient self-report without objective monitoring of activity progression 1

Patient Education Essentials

Provide written discharge instructions covering 1:

• Warning signs of serious injury requiring emergency care
• Expected symptom course and recovery timeline
• How to monitor postconcussive symptoms
• Prevention of further injury during recovery
• Specific activity management plan with clear follow-up instructions

The evidence strongly supports this balanced approach: the 2023 PM&R consensus panel reviewed 6,303 articles and found that both extremes—strict rest and high-intensity activity—cause harm, while graduated sub-symptom threshold exercise (particularly in adolescents) promotes recovery 1. The CDC pediatric guidelines similarly emphasize brief initial rest followed by active rehabilitation 1.