What are the recommendations for a teenager with 3-4 traumatic brain injuries (TBI) due to concussion?

From the Guidelines

For a teenager with 3-4 concussions, immediate medical evaluation by a neurologist or sports medicine specialist is strongly recommended. This recommendation is based on the most recent guidelines from the American Heart Association and American Red Cross, which emphasize the importance of removing individuals with signs and symptoms of a concussion from activity and not allowing them to return until evaluated by a healthcare professional 1.

Key Recommendations

• Complete physical and cognitive rest is essential during the acute recovery phase, typically 24-48 hours, followed by a gradual return to activities under medical supervision.
• The teenager should avoid all contact sports and high-risk activities for at least 3-6 months, possibly longer depending on symptom severity and recovery patterns.
• No specific medications are universally prescribed for concussion recovery, though acetaminophen may be used for headache management (typically 500-650mg every 6 hours as needed, not exceeding 3000mg daily) 1.
• NSAIDs like ibuprofen should generally be avoided in the acute phase.
• Sleep hygiene, proper nutrition, and hydration are important for recovery.
• A structured return-to-learn protocol should be implemented before any return-to-play consideration, with academic accommodations as needed.

Considerations for Multiple Concussions

Multiple concussions in adolescents are particularly concerning because the developing brain is more vulnerable to injury and may have longer recovery times 1. Some teenagers with multiple concussions may need to consider permanent retirement from high-risk sports to prevent potential long-term cognitive consequences. The Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children suggests that healthcare professionals should counsel children and families about the potential for delayed recovery in those with premorbid histories of mTBI, lower cognitive ability, neurological or psychiatric disorder, learning difficulties, increased preinjury symptoms, and family and social stressors 1.

From the Research

Recommendations for a Teenager with 3-4 Concussions

• The treatment for concussion should be individualized, based on predominant signs and symptoms 2
• A gradual increase in activity may potentially aid in returning to normal daily activity sooner than those who avoid both physical and cognitive activity during the acute stage of a traumatic brain injury 3
• Exercise is recommended as an appropriate therapy for adolescents with acute concussion/mTBI 4
• Strict rest and high-intensity physical activity may have detrimental effects 4
• A multidisciplinary approach may be required for clinical management, including subsymptom threshold aerobic exercise, cervical physical therapy, vestibulo-ocular rehabilitation, behavioral and cognitive psychotherapy, and some symptom-specific pharmacological therapies 2

Physical Examination and Assessment

• The physical examination elements for concussion include evaluation of cranial nerves, manual muscle testing, and deep tendon reflexes; inspecting the head and neck for trauma or tenderness and cervical range of motion; Spurling maneuver; a static or dynamic balance assessment; screening ocular examination; and a mental status examination 5
• Other examination elements to consider include testing of upper motor neurons, cervical strength and proprioception, coordination, pupillary reactivity, and visual acuity; examination of the jaw, temporomandibular joint, and thoracic spine; fundoscopic evaluation; orthostatic vital signs; assessment of dynamic visual acuity; and screening for depression, anxiety, substance abuse disorders, and preinjury psychiatric difficulties 5

Return to Activity Protocols

• There is limited guidance on the use of specific therapeutic interventions for return to activity protocols 4
• The evidence on return to activity protocols for the management of concussion/mTBI remains limited to small randomized controlled trials and observational studies of moderate to low quality 4
• High-quality randomized studies with sufficient power are needed to evaluate the effects of return to activity protocols for the management of concussion/mTBI 4