What is the standard protocol for managing a concussion?

Concussion Management Protocol

Remove the patient from activity immediately and do not allow return to play the same day, even if symptoms resolve—this is the single most critical safety measure. 1, 2

Immediate Assessment and Red Flags

Evaluate immediately for high-risk features requiring emergency CT imaging:

• Altered mental status, loss of consciousness, or Glasgow Coma Scale <15 2
• Severe or worsening headache, repeated vomiting, or seizure activity 2
• Focal neurological deficits or signs of skull fracture 2
• Dangerous mechanism of injury or any coagulopathy/anticoagulant use 2

If any red flags are present, obtain non-contrast head CT and consider emergency department evaluation. 2

Acute Management (First 24-48 Hours)

Implement moderate physical and cognitive rest for 24-48 hours only—strict rest beyond 3 days is detrimental and worsens outcomes. 1, 2, 3

Physical rest includes:

• No sports, exercise, or strenuous physical activity 2
• Avoiding activities that significantly increase heart rate 2
• No contact or collision activities 2

Cognitive rest includes:

• Limiting screen time 2
• Reducing academic workload 2
• Avoiding activities requiring intense concentration 2

Gradual Return to Activity (After 24-48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial rest period—exercise is strongly recommended as appropriate therapy, particularly for adolescents. 1, 2

Follow this stepwise progression, with each step requiring minimum 24 hours and complete symptom resolution before advancing:

1. Light aerobic exercise: Walking, swimming, or stationary cycling 1, 2, 3
2. Sport-specific exercise: Skating drills in hockey, running drills in soccer 1, 3
3. Non-contact training drills: Passing drills, resistance training 1, 3
4. Full-contact practice: Only after medical clearance 1, 3
5. Return to competition 1, 3

If any symptoms recur at any step, drop back to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 1, 2, 3

Return to School/Academics

Gradually increase academic activities as tolerated, implementing accommodations as needed:

• Shortened school days 2
• Extended time for assignments and tests 2
• Reduced workload 2
• Breaks during the day as needed 2

Absolute Contraindications to Return to Play

Do not clear for return to play if:

• Taking any medications for concussion symptoms 1, 2, 3
• Persistent symptoms at rest 1, 2
• Symptoms recur with exertion 1, 2
• Not returned to premorbid performance level 2, 3

Management of Persistent Symptoms (>10 Days)

Implement multidisciplinary management for symptoms lasting beyond 10 days, as 15-20% develop persistent post-concussion syndrome. 1, 2, 3

Multidisciplinary approach includes:

• Formal neuropsychological assessment 1, 2
• Graded physical exercise programs 1, 3
• Vestibular rehabilitation 3
• Psychological treatment 1, 3
• Assessment for preexisting comorbidities (mood disorders, learning disabilities, ADHD, migraine) 2

Critical Pitfalls to Avoid

Never allow same-day return to play, even if asymptomatic—this is non-negotiable. 1, 2, 3

Avoid strict rest exceeding 3 days—prolonged activity restriction causes physical deconditioning and psychological consequences that worsen outcomes. 1, 2, 3

Do not advance through the return-to-play protocol while taking concussion symptom medications—this masks symptoms and increases risk. 1, 2, 3

Avoid high-intensity physical activity during recovery—this is detrimental to healing. 1, 4

Special Populations

Adolescents have the strongest evidence for exercise as therapy and should begin supervised aerobic activity after initial 24-48 hour rest. 1, 2

Younger athletes require more conservative management with stricter return-to-play guidelines and typically experience longer recovery times. 3, 5

Most patients recover within 7-10 days, though some may take weeks to months—recovery timeline varies significantly by individual. 2