What is the recommended treatment for a concussion in a youth?

Treatment of Concussion in Youth

Youth with concussion require immediate removal from play, complete physical and cognitive rest until asymptomatic, followed by a minimum 5-day graded return-to-play protocol—never return to play the same day of injury. 1

Immediate Management

Remove from Activity

• Any youth suspected of concussion must be immediately removed from play and not return the same day, even if symptoms resolve 1
• The principle "When in doubt, sit them out!" is paramount 1
• Youth with loss of consciousness or amnesia should be disqualified from further participation that day 1
• Medical evaluation by a physician experienced in concussion management should occur as soon as possible 1, 2, 3

Rest Protocol (Acute Phase)

Physical Rest

• Complete physical rest is required until the youth is asymptomatic at rest 1
• Avoid all physical exertion, as increased energy demand may exacerbate symptoms and prolong recovery 1
• Youth should avoid activities that increase symptoms but complete bed rest is not recommended 1

Cognitive Rest

• Cognitive rest is essential and may require temporary school absence or modified school schedule 1, 3
• Specific accommodations include: shortened school day, reduced workload, extended time for assignments and tests, and avoidance of standardized testing during recovery 1
• Restrict activities requiring concentration: video games, computer use, television viewing, reading (even for leisure), and loud music 1
• Communication with school nurses, administrators, and teachers is imperative to ensure proper accommodations 1

Important caveat: While strict prolonged rest was historically recommended, emerging evidence suggests that excessive activity restriction beyond the acute symptomatic phase may worsen outcomes and contribute to persistent symptoms 4. However, this applies to prolonged restriction, not the initial rest period.

Medication Considerations

• No medications are proven effective for treating concussion in youth 1
• Acetaminophen may be used for symptom management if recommended by a physician 1
• NSAIDs and aspirin should be avoided immediately after injury due to theoretical risk of intracranial bleeding, though no documented harm exists in sport-related concussion 1
• Avoid alcohol, illicit drugs, and substances that interfere with cognitive function 1
• Any medication used to control symptoms indicates incomplete recovery; youth must be symptom-free off medication before return to play 1

Return-to-Play Protocol

Timing Considerations

• Youth require 7-10 days or longer for full cognitive recovery, significantly longer than college or professional athletes 1
• Most youth become asymptomatic within one week, but cognitive function takes longer to normalize 1
• More conservative management is mandatory for youth under 18 years due to the maturing brain 1

Graded Return-to-Play (Minimum 5 Days)

Once completely asymptomatic at rest and with full return to school achieved, progress through this stepwise protocol 1:

1. No activity: Complete physical and cognitive rest 1
2. Light aerobic activity (24 hours minimum): Walking, swimming, or stationary cycling at 70% maximum heart rate; no resistance exercises 1
3. Sport-specific exercise (24 hours minimum): Sport-related drills without head impact 1
4. Noncontact training drills (24 hours minimum): More complex drills; may start light resistance training 1
5. Full-contact practice (24 hours minimum): After medical clearance, participate in normal training 1
6. Return to play: Normal game participation 1

If symptoms return at any stage: Stop immediately, rest for 24 hours after becoming asymptomatic, then resume at the previous asymptomatic level 1

Special Considerations

Multiple Concussions

• Youth with history of 3+ concussions or symptoms lasting >3 months should be strongly considered for prolonged time away from sports 1
• Athletes with multiple concussions have increased risk of subsequent injuries and slower recovery 1
• Referral to a concussion specialist is recommended if considering permanent removal from sports 1

Persistent Symptoms (>10 Days)

• Approximately 15-20% of youth develop persisting symptoms 1
• These youth may require longer rehabilitation programs created by physicians experienced in concussion management 1
• Assess for preexisting conditions (mood disorders, high initial symptom load) which predict prolonged recovery 1

Younger Athletes

• Pediatric athletes (<13 years) may require even longer recovery periods and more frequent baseline measure updates 1
• Almost all cases of second-impact syndrome (catastrophic outcome) occur in youth, mandating stricter management 1

Common Pitfalls to Avoid

• Never allow same-day return to play, even if asymptomatic 1
• Do not rely solely on neuropsychological testing; symptomatic athletes should not return to play even with normal testing 1
• Avoid underestimating cognitive difficulties because youth "look well" physically 1
• Do not rush return to school or sports; inadequate rest may prolong recovery 1
• Recognize that structural neuroimaging (CT/MRI) is typically normal in concussion and does not guide management 1