What is the recommended treatment for a patient with a mild to moderate concussion?

Concussion Treatment

For mild to moderate concussion, implement 24-48 hours of moderate physical and cognitive rest, then immediately begin supervised, sub-threshold aerobic exercise with gradual progression back to full activity—avoiding prolonged rest beyond 3 days, which worsens outcomes. 1, 2

Immediate Management (First 24-48 Hours)

Remove from activity immediately when concussion is suspected—"When in doubt, sit them out!" 1, 3

Initial Rest Period

• Implement moderate physical and cognitive rest for 24-48 hours only to allow initial recovery during the acute neurometabolic cascade 1, 2, 3
• Physical rest includes no sports, exercise, or strenuous physical activity 2
• Cognitive rest includes limiting screen time, reducing academic workload, and avoiding activities requiring intense concentration 2
• Critical: Do not exceed 3 days of strict rest—prolonged rest actually worsens outcomes and delays recovery 1, 3, 4

Red Flags Requiring Emergency Evaluation

Monitor for warning signs requiring immediate medical attention: 1, 2

• Loss of consciousness or altered mental status
• Severe or worsening headache
• Repeated vomiting
• Seizures
• Focal neurological deficits
• Visual changes

Medication Management

• Use acetaminophen only for symptom management, and only as recommended by a physician 1, 3
• Avoid NSAIDs/aspirin due to theoretical bleeding risk 3
• Do not return to activity while taking any medications for concussion symptoms—this indicates incomplete recovery 1, 2

Gradual Return to Activity (After 48 Hours)

This is the cornerstone of treatment. After the initial 24-48 hour rest period, begin supervised, sub-threshold aerobic exercise—this is the only intervention with strong evidence, particularly in adolescents. 5, 1, 2

Stepwise Progression Protocol

Each step requires minimum 24 hours and must be completely symptom-free before advancing: 1, 2

1. Light aerobic exercise (walking, swimming, stationary cycling below symptom threshold) 1, 2
2. Sport-specific exercise (skating drills in hockey, running drills in soccer) 1, 2
3. Non-contact training drills (passing drills, resistance training) 1, 2
4. Full-contact practice (following medical clearance) 1, 2
5. Return to competition 1, 2

Critical Rules for Progression

• If symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again 1, 2
• Introduce supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold 1, 2
• Monitor symptom expression (number and severity) closely during each step 1

Return to School/Cognitive Activities

Gradually increase duration and intensity of academic activities as tolerated after the initial 24-48 hour rest period 1, 2

Academic Accommodations (if needed)

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

Criteria for Full Return to Activity

Allow return to full activity only when ALL of the following are met: 1, 2

• Returned to premorbid performance level
• Remains completely symptom-free at rest
• Shows no symptom recurrence with increasing physical exertion
• Not taking any medications for concussion symptoms

Management of Persistent Symptoms (Beyond 10 Days)

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

Multidisciplinary Approach Includes:

• Formal neuropsychological assessment 1, 2
• Graded physical exercise programs 1, 3
• Vestibular rehabilitation 1, 3
• Manual therapy for neck pain 1, 3
• Oculomotor vision treatment 1, 3
• Psychological treatment 1, 3

Special Considerations

Adolescents

• Exercise is an appropriate intervention for adolescents with acute concussion based on high-quality RCTs 5
• Two high-quality RCTs in adolescents demonstrated aerobic exercise is appropriate therapy for acute concussion 5
• Recovery may take longer in younger athletes; manage more conservatively with stricter return-to-play guidelines 1

Evidence Quality Note

The 2023 consensus statement found exercise is appropriate for adolescents with acute concussion, though evidence for other age groups remains uncertain due to moderate to high risk of bias in most studies. 5

Critical Pitfalls to Avoid

• Never allow same-day return to play, even if symptoms completely resolve 1, 2
• Avoid prolonged rest exceeding 3 days—this is counterproductive and worsens outcomes 1, 3, 4
• Do not return to play while taking medications for concussion symptoms 1, 2
• Avoid high-intensity physical activity during recovery—this can be detrimental 1, 3
• Do not rely solely on patient-reported symptoms without objective assessment 1, 3
• Inadequate rest during the acute 24-48 hour phase 1
• Returning to activity too soon, which can worsen outcomes or prolong recovery 1