Does a concussion in an otherwise healthy individual require treatment?

Does Concussion Require Treatment?

Yes, concussion absolutely requires treatment—specifically cognitive and physical rest for 24-48 hours followed by a structured, graded return-to-activity protocol, with immediate removal from any activity at the time of injury. 1, 2

Immediate Management is Mandatory

Remove the patient immediately from all physical activity—"when in doubt, sit them out"—and do not allow same-day return under any circumstances. 2, 3 This is non-negotiable regardless of symptom resolution, as the underlying neurometabolic cascade continues even when symptoms appear to improve. 1, 2

Initial 24-48 Hour Rest Period

• Implement both cognitive and physical rest for the first 24-48 hours after injury. 2, 4 This allows the brain to recover during the acute neurometabolic cascade when energy demand is increased while cerebral blood flow is decreased. 1, 2

• Cognitive rest means temporary reduction in school workload, avoidance of video games, computer use, television, and loud music. 1, 2

• Critical pitfall: Do NOT prescribe strict prolonged rest exceeding 3 days, as this worsens outcomes and is detrimental to recovery. 1, 2 The evidence from randomized controlled trials demonstrates that excessive rest beyond the initial 48 hours actually impairs recovery. 1

Structured Return-to-Activity Protocol (Days 3+)

After the initial rest period, begin a mandatory stepwise progression protocol that takes a minimum of 5 days to complete. 1, 2 Each step requires at least 24 hours before advancing:

1. Light aerobic activity (walking, swimming, stationary cycling at 70% maximum heart rate; no resistance exercises) 1, 2

2. Sport-specific exercise (specific drills but no head impact) 1, 2

3. Non-contact training drills (more complex drills, may start light resistance training) 1, 2

4. Full-contact practice (after medical clearance, participate in normal training) 1, 2

5. Return to play (normal game play) 1, 2

If any symptoms recur at any step, immediately stop, rest for 24 hours after becoming asymptomatic, then resume at the previous asymptomatic level. 1, 2, 3

Why Treatment Cannot Be Skipped

The evidence is clear that appropriate management reduces the risk of long-term symptoms and complications. 1 Without proper treatment:

• 15-20% of patients develop persistent symptoms beyond 2 weeks that can include long-term cognitive and physical impairment, adverse mental health conditions, and decreased quality of life. 1, 2

• Risk of second impact syndrome exists if the athlete returns to activity before the neurometabolic cascade has resolved, which can be catastrophic particularly in the developing brain. 1

• Prolonged recovery and worse outcomes occur when patients either rest too much (>3 days strict rest) or return to activity too quickly. 1, 2

Symptom Management

• Use acetaminophen for headache management; avoid NSAIDs and aspirin due to theoretical bleeding risk. 2

• Do not use vestibular suppressants like meclizine or benzodiazepines as they provide no benefit and may interfere with central compensation mechanisms critical for recovery. 2

When to Escalate Care

Arrange follow-up with a healthcare professional trained in concussion management within 24-48 hours, even if symptoms appear mild. 3

Refer to a traumatic brain injury specialist if symptoms persist beyond 10 days to 3 weeks. 2 At this point, implement multidisciplinary management including vestibular rehabilitation, cervical physical therapy, vision therapy, and cognitive behavioral therapy as indicated. 2

Special Considerations for Pediatric Patients

Be more conservative with children and adolescents (<18 years) as their developing brains are more susceptible to concussion effects and may require longer recovery periods. 1, 4 The American Academy of Pediatrics emphasizes that young athletes have repeatedly demonstrated significant impacts on academic performance and are at higher risk for long-term sequelae. 1

Common Pitfalls to Avoid

• Never allow return to play while taking medications for concussion symptoms—this indicates incomplete recovery. 2

• Do not rely solely on patient self-report, as athletes (particularly males) often minimize symptoms to return to play. 3

• Loss of consciousness occurs in less than 10% of concussions—its absence does not mean the injury is less serious or requires less treatment. 3, 5