What are the recommended brain rest instructions after a concussion?

Brain Rest Instructions After Concussion

After a concussion, implement complete physical and cognitive rest for 24-48 hours, then begin a supervised, gradual return to activities rather than prolonged complete rest, which can actually worsen outcomes. 1, 2

Immediate Post-Injury Period (First 24-48 Hours)

Complete rest is essential during the acute neurometabolic cascade when the brain is most vulnerable:

• Physical rest: No sports, exercise, or strenuous physical activity that significantly increases heart rate 3
• Cognitive rest: Limit all activities requiring concentration including reading, video games, computer use, television, loud music, and bright lights 2
• Avoid screen time and reduce activities requiring intense concentration 3
• Use only acetaminophen for pain if needed, and only as recommended by a physician—avoid all other medications 1, 2
• Avoid alcohol, illicit drugs, or any substances that interfere with cognitive function 2

This 24-48 hour window is critical because prolonged rest beyond 3 days can be detrimental and may worsen outcomes. 4, 5

After Initial 24-48 Hours: Gradual Activity Resumption

Once the acute period passes, begin supervised, sub-threshold aerobic exercise rather than continuing complete rest:

• Start light aerobic exercise below the symptom exacerbation threshold 1, 3
• Gradually increase intensity as tolerated, but stop immediately if any symptoms return 1, 2
• Research shows that early, graded exercise aids neurorehabilitation and reduces symptom duration 3, 6

Academic Accommodations

Implement temporary school modifications immediately:

• Shortened school days with gradual increases in duration as tolerated 1, 2
• Reduced workloads and extended time for assignments and tests 1, 3
• Postponement of standardized testing 1, 2
• Breaks during the day as needed 3
• Gradually increase academic activities based on symptom tolerance 3

Stepwise Return-to-Activity Protocol

Follow a structured 5-6 step progression, with each step requiring a minimum of 24 hours:

1. No activity (initial 24-48 hour rest period) 1, 2
2. Light aerobic exercise (walking, stationary cycling at <70% maximum heart rate) 2, 3
3. Sport-specific exercise (running drills, no head impact) 2, 3
4. Non-contact training drills (more complex training activities) 2, 3
5. Full-contact practice (normal training activities) 2, 3
6. Return to competition (normal game play) 2, 3

Critical rule: If ANY symptoms recur at any stage, immediately drop back to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 7, 1, 2

Absolute Restrictions

Never allow return to play if:

• On the same day of injury, under any circumstances 7, 1, 2
• Taking any medications for concussion symptoms (pain relievers, anti-nausea medications, or sleep aids) 7, 1, 2
• Any symptoms persist at rest 3
• Symptoms recur with exertion 3

Warning Signs Requiring Emergency Evaluation

Seek immediate medical attention for:

• Repeated vomiting or worsening headache 1, 2
• Loss of consciousness or seizures 1, 2
• Altered mental status, confusion, or abnormal behavior 1, 2
• Visual changes or focal neurologic deficits 1, 2
• Increased sleepiness or difficulty waking 3

Management of Persistent Symptoms (>10 Days)

Symptoms lasting beyond 10 days require multidisciplinary management, affecting 15-20% of patients:

• Formal neuropsychological assessment for cognitive symptoms 2, 3
• Graded physical exercise programs under professional guidance 2, 3
• Vestibular rehabilitation for balance and dizziness symptoms 2, 3
• Manual therapy of the neck and spine 2
• Psychological treatment if needed 3

Critical Pitfalls to Avoid

The most dangerous mistake is returning to activity too soon, which can worsen outcomes, prolong recovery, or risk second-impact syndrome. 1, 2

• Do not exceed 3 days of strict complete rest—prolonged inactivity worsens outcomes through physical deconditioning and psychological consequences 3, 8, 5
• Do not skip steps in the return-to-play protocol 2
• Do not rely solely on patient-reported symptoms without objective assessment 2
• Do not underestimate recovery time in younger athletes, who require more conservative management 1, 2

Special Considerations for Younger Athletes

Manage adolescents and children more conservatively with stricter return-to-play guidelines:

• Younger athletes generally require longer recovery times 1
• Damage to the maturing brain can be catastrophic 2
• Most teenagers recover within 7-10 days, though some may take weeks to months 3
• Athletes with three or more prior concussions who experience slowed recovery may require temporary or permanent disqualification from contact sports 2