What are the recommendations for managing a concussion?

Concussion Management Recommendations

Immediately remove any athlete or individual from activity if concussion is suspected, and do not allow return to play on the same day of injury—this is non-negotiable. 1, 2

Immediate Management and Initial Rest Period

Complete physical and cognitive rest for 24-48 hours after injury is essential, followed by gradual return to activity only when the patient becomes asymptomatic at rest. 1, 2 This initial rest period is critical, but prolonged rest beyond 3 days may actually worsen outcomes and delay recovery. 3

Cognitive Rest Specifics (First 24-48 Hours)

• Limit all activities requiring concentration: reading, video games, computer use, television, loud music, and bright lights 1, 2
• Implement temporary academic accommodations including shortened school days, reduced workloads, extended time for assignments, and postponement of standardized testing 1

Warning Signs Requiring Emergency Evaluation

Seek immediate medical attention for: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes, or scalp swelling/deformities. 1, 2

Medication Management

Avoid all medications except acetaminophen, and only as recommended by a physician. 1, 2 Never allow return to play while taking any medications for concussion symptoms. 1, 2

Avoid alcohol, illicit drugs, or any substances that interfere with cognitive function during recovery. 2

Stepwise Return-to-Activity Protocol

Each step must take a minimum of 24 hours; if any symptoms recur at any stage, drop back to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 1, 2, 4

The Six-Step Protocol:

1. No activity: Complete rest until asymptomatic at rest 2, 4
2. Light aerobic exercise: Walking, swimming, or stationary cycling at <70% maximum heart rate; no resistance training 2, 4
3. Sport-specific exercise: Skating drills, running drills; no head impact activities 2, 4
4. Non-contact training drills: Progression to more complex training drills; may start progressive resistance training 2, 4
5. Full-contact practice: Following medical clearance by healthcare professional trained in concussion management 2, 4
6. Return to competition: Normal game play 2, 4

Management of Persistent Symptoms (Beyond 10 Days)

Symptoms persisting beyond 10 days require multidisciplinary management, affecting 15-20% of concussion patients. 1 At this stage, prolonged strict rest is likely counterproductive. 5, 6, 3

For patients with persistent symptoms, consider:

• Graded physical exercise under professional guidance 2
• Vestibular rehabilitation for balance/dizziness symptoms 2
• Manual therapy of the neck and spine 2
• Formal neuropsychological assessment for cognitive symptoms 1
• Supervised exercise programs, which may actually benefit recovery 5, 3

The evidence suggests that complete rest exceeding 3 days is probably not helpful, and gradual resumption of activities should begin as tolerated. 3 Prolonged activity restriction can lead to physical deconditioning, social isolation, and may contribute to persistent symptoms through an "activity restriction cascade." 6

Special Populations Requiring Conservative Management

Children and Adolescents (<18 years)

Manage younger athletes more conservatively with stricter return-to-play guidelines because damage to the maturing brain can be catastrophic. 7, 1, 2 Recovery typically takes longer in younger athletes compared to older ones. 7, 1, 2

Athletes with History of Multiple Concussions

Athletes with three or more prior concussions who experience slowed recovery may require temporary or permanent disqualification from contact sports. 7 These athletes have increased risk of subsequent injuries and slower recovery. 7

Disqualification Criteria

Disqualify from same-day return if:

• Any loss of consciousness or amnesia occurred 7
• Symptoms persist at rest or after 20 minutes of exertion (jogging, sprinting, sit-ups, push-ups, sport-specific movements) 7
• Any symptoms whatsoever are present 2, 4

Critical Pitfalls to Avoid

The most dangerous mistake is allowing return to play too soon, which can worsen outcomes, prolong recovery, or risk second-impact syndrome. 1, 2 Other critical errors include:

• Skipping steps in the return-to-play protocol even if the athlete appears to recover quickly 4
• Prescribing excessive prolonged rest beyond the initial 24-48 hours, which may worsen outcomes 6, 3
• Relying solely on patient-reported symptoms without objective assessment 1
• Underestimating recovery time in younger athletes 2
• Failing to identify and manage persistent symptoms beyond 10 days 1

Team-Based Decision Making

Return-to-play decisions should involve a team approach including the athletic trainer, physician, athlete, and any referral sources, considering physical examination, imaging studies, objective tests, and exertional efforts. 7 Medical clearance must be provided by a healthcare professional trained in concussion management before full-contact practice. 4