What is the recommended management plan for a patient with a concussion?

Concussion Management

Immediate Management: Remove from Activity and Initial Rest

Immediately remove the patient from play or activity when concussion is suspected—"When in doubt, sit them out!"—and never allow same-day return to activity, even if symptoms completely resolve. 1, 2

• Monitor for red flag symptoms requiring emergency evaluation: loss of consciousness, altered mental status, severe or worsening headache, repeated vomiting, seizures, focal neurological deficits, or signs of basilar skull fracture 1, 2
• Obtain non-contrast head CT if any high-risk features are present: GCS <15, loss of consciousness, post-traumatic amnesia, vomiting, severe headache, dangerous mechanism, or coagulopathy 2
• Implement complete physical and cognitive rest for the first 24-48 hours only—this is the critical window for initial recovery 1, 2, 3
• Physical rest means no sports, exercise, or activities that significantly increase heart rate 2
• Cognitive rest means limiting screen time, reducing academic workload, and avoiding activities requiring intense concentration 2, 3

Critical pitfall to avoid: Do not prescribe strict rest beyond 48-72 hours, as prolonged rest (>3 days) actually worsens outcomes and delays recovery 4, 1, 2

Gradual Return to Activity: The Evidence-Based Core of Management

After the initial 24-48 hour rest period, begin supervised, sub-threshold aerobic exercise—this is the only intervention with strong evidence as an appropriate therapy, particularly in adolescents. 4, 1, 2

The stepwise progression protocol includes:

1. Light aerobic exercise (walking, swimming, stationary cycling) that stays below symptom-exacerbation threshold 1, 2
2. Sport-specific exercise (skating drills, running drills) without contact 1, 2
3. Non-contact training drills (passing drills, resistance training) 1, 2
4. Full-contact practice (only after medical clearance) 1, 2
5. Return to competition 1, 2

Each step requires a minimum of 24 hours and must be symptom-free before advancing. 1, 2, 3

• If symptoms recur during any step, return to the previous asymptomatic level and attempt progression again after 24 hours of rest 1, 3
• The evidence shows that both extremes are harmful: high-intensity physical activity is detrimental, but prolonged avoidance of exercise also has negative consequences 4, 1

Return to School/Cognitive Activities

Gradually increase academic activities as tolerated, implementing temporary accommodations if symptoms interfere with performance. 1, 2, 3

Specific accommodations include:

• Shortened school days 1, 2, 3
• Reduced workloads 1, 2, 3
• Extended time for assignments and tests 1, 2, 3
• Breaks during the day as needed 2
• Postponement of standardized testing 3

Medication Management: Minimal Intervention

Use only acetaminophen for symptom management, and only as recommended by a physician—avoid all other medications during the acute recovery phase. 1, 2, 3

• Do not clear patients for return to play if they are taking any medications for concussion symptoms 1, 2
• There are no FDA-approved medications for acute concussion treatment 5

Return to Full Activity Criteria

Allow return to full activity only when the patient has returned to premorbid performance level, remains completely symptom-free at rest, and shows no symptom recurrence with increasing physical exertion. 1, 2

• Medical clearance from a physician experienced in concussion management is required before full return to play 2
• Most patients recover within 7-10 days, though some may take weeks to months 2

Management of Persistent Symptoms (>10 Days)

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

The multidisciplinary approach should include:

• Formal neuropsychological assessment for persistent cognitive symptoms 1, 3
• Graded physical exercise programs 1, 2
• Vestibular rehabilitation if indicated 1
• Manual therapy for cervical symptoms 1
• Psychological treatment 1, 2
• Oculomotor vision treatment if needed 1

Special Population Considerations

Manage pediatric and adolescent patients more conservatively with stricter return-to-play guidelines, as recovery takes longer in younger athletes and they face higher risk of catastrophic injury. 2, 3

• Exercise therapy has the strongest evidence specifically in adolescents, making it the cornerstone of management in this age group 4, 2
• Older patients often experience concussions from low-velocity mechanisms such as falls from standing height 1

Assessment and Monitoring

Use objective assessment tools in combination with symptom checklists rather than relying solely on patient self-report, as patients may under-report or over-report symptoms. 4, 2

Recommended assessment battery includes:

• Graded symptom checklists 2
• Cognitive screening 2
• Balance testing 2
• Neuropsychological testing when available for baseline comparison 2, 3

Common pitfall: Underreporting may lead to premature return to activity and increased risk of future concussions, while overreporting may lead to prolonged rest with negative implications for recovery and mental/physical wellbeing 4

Key Evidence Limitations

The 2023 PM&R consensus statement found that most studies were of moderate to high risk of bias, with patients mainly recruited from specialty clinics (suggesting more severe symptoms than the general population), and many lacked rigorous randomization methods 4. Despite these limitations, the panel found sufficient evidence to recommend exercise for adolescents with acute concussion, while finding evidence of detrimental effects from both strict rest and high-intensity physical activity 4.