What are the management guidelines for a patient with a concussion?

Concussion Management

Immediately remove any patient with suspected concussion from activity and do not allow return to play on the same day, regardless of symptom resolution. 1, 2

Immediate Assessment and Red Flags

Activate EMS immediately if any of the following severe features are present: 1, 3

• Loss of consciousness
• Worsening or severe headache
• Repeated vomiting
• Altered mental status or confusion
• Seizure activity
• Visual changes
• Focal neurological deficits
• Swelling or deformities of the scalp

Monitor vital signs and level of consciousness every 5 minutes until the patient's condition improves or they are transferred to emergency care. 2, 3

Initial Management (First 24-48 Hours)

Prescribe complete physical and cognitive rest for 24-48 hours only. 2, 3 Prolonged rest beyond 48-72 hours actually worsens outcomes and delays recovery. 3, 4

Physical rest includes: 3

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

Cognitive rest includes: 3

• Limiting screen time
• Reducing academic workload with accommodations (shortened school days, extended time for tests, reduced workload)
• Avoiding activities requiring intense concentration

For pain management, use only acetaminophen as recommended by a physician—avoid all other medications including NSAIDs. 1, 3 Instruct patients to avoid alcohol and any substances that interfere with cognitive function. 1

Return-to-Activity Protocol

Begin supervised, sub-threshold aerobic exercise after the initial 24-48 hour rest period. 2, 3 This is the only intervention with strong evidence as appropriate therapy, particularly in adolescents. 2, 3

Follow this stepwise progression, with each step requiring a minimum of 24 hours and complete symptom resolution before advancing: 1, 2, 3

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

If any symptoms recur during a step, immediately return to the previous symptom-free level and remain there for 24 hours before attempting to advance again. 2, 3

Critical Disqualification Criteria

Do not clear for return to play if: 2, 3

• Taking any medications for concussion symptoms
• Persistent symptoms at rest
• Symptoms occur with exertion
• Less than 7 days have passed without standardized assessment tools 2

Assessment Tools

Use a structured evaluation battery including: 2

• Standardized symptom checklist (document severity and progression)
• Brief cognitive testing (orientation, memory, concentration)
• Balance Error Scoring System (BESS)
• Neurological examination

Neuropsychological testing should supplement, not replace, clinical assessment and must be interpreted by professionals trained in the specific test's limitations. 5 Most concussions can be managed appropriately without neuropsychological testing. 5

Management of Persistent Symptoms (>3 Weeks)

Refer to specialists and implement targeted interventions based on concussion subtype: 2, 3

• Vestibular symptoms: Vestibular rehabilitation
• Cognitive symptoms: Formal neuropsychological assessment
• Headache/migraine: Manual therapy, targeted pharmacotherapy
• Anxiety/mood: Psychological treatment
• All subtypes: Graded physical exercise programs

Use a multidisciplinary team approach involving athletic trainers, physicians, and specialists to integrate physical examination, imaging studies, objective testing, and exertional testing results. 2

Special Population Considerations

Manage pediatric and adolescent patients (<18 years) more conservatively with stricter return-to-play guidelines, as they have longer recovery times and increased risk of catastrophic second-impact syndrome. 2, 3

Patients with concussion history require more conservative management due to increased risk of subsequent injuries, slowed recovery, and prolonged cognitive dysfunction. 2

Assess for preexisting comorbidities (mood disorders, learning disabilities, ADHD, migraine headaches) as these complicate diagnosis and management. 5

Common Pitfalls to Avoid

• Never allow same-day return to play, even if symptoms completely resolve 1, 2, 3
• Do not prescribe strict rest beyond 48-72 hours—this worsens outcomes 3, 4
• Do not rely solely on patient self-report—use objective assessment tools 2
• Do not use rigid cervical collars or long spine boards for routine spinal immobilization 1

Expected Recovery Timeline

Most patients recover within 7-10 days, though adolescents may take longer. 3 Symptoms persisting beyond 3 weeks warrant specialist referral and targeted interventions. 2, 3