What is the recommended management for a 13-year-old female patient with a concussion?

Concussion Management in a 13-Year-Old Female

Implement 24-48 hours of moderate physical and cognitive rest immediately after injury, followed by early introduction of supervised sub-threshold aerobic exercise, as prolonged rest beyond 3 days worsens outcomes and delays recovery in adolescents. 1, 2

Immediate Management (First 24-48 Hours)

Remove from activity immediately - never allow same-day return to play, even if symptoms resolve completely. 1, 3

Physical Rest

• No sports, exercise, or strenuous physical activity 3
• Avoid activities that significantly increase heart rate 3
• No contact or collision activities 3

Cognitive Rest

• Limit screen time (video games, computer, television) 1
• Reduce academic workload 1, 3
• Avoid activities requiring intense concentration 3
• Consider temporary leave from school or shortened school day 1
• Avoid loud music, use sunglasses if photophobia present 1

Critical Warning Signs Requiring Emergency Evaluation

• Loss of consciousness or altered mental status 3
• Repeated vomiting 3
• Severe or worsening headache 3
• Seizure activity 3
• Focal neurological deficits 3

Gradual Return to Activity (After 48-72 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial rest period - this is the only intervention with strong evidence supporting its use in adolescents with acute concussion. 1, 2

Progressive Exercise Protocol

Each step requires minimum 24 hours and complete symptom resolution before advancing: 1, 3

1. Light aerobic exercise - walking, swimming, stationary cycling at intensity that does not provoke symptoms 1, 3, 4
2. Sport-specific exercise - skating drills, running drills without contact 3, 4
3. Non-contact training drills - passing drills, resistance training 3, 4
4. Full-contact practice - only after medical clearance 3, 4
5. Return to competition 3, 4

If symptoms recur at any step, return to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 4

Key Principle

The exercise should remain below the symptom-exacerbation threshold - meaning the activity should not provoke or worsen symptoms. 1, 2

Return to School/Academics

Begin gradual reintegration after the initial 24-48 hour rest period, with accommodations as needed: 1

• Shortened school days 1, 3
• Extended time for assignments and tests 1, 3
• Reduced workload 1, 3
• Breaks during the day as needed 3
• Allow adequate time to make up assignments with reduced overall volume 1
• Avoid standardized testing during recovery 1

Educate teachers, counselors, and administrators about cognitive effects of concussion, as students physically appear well but may have significant difficulties. 1

Medication Guidelines

Use only acetaminophen for symptom management, and only as recommended by a physician. 3

• No evidence supports NSAIDs or other medications for shortening concussion course 1
• Avoid NSAIDs immediately after injury due to theoretical risk of intracranial bleeding 1
• Do not return to play while taking any medications for concussion symptoms - this indicates incomplete recovery 1, 3

Return to Full Activity Criteria

Allow return to full activity only when all of the following are met: 1, 3

• Returned to premorbid performance level 1
• Completely symptom-free at rest 1
• No symptom recurrence with increasing physical exertion 1
• Medical clearance from physician experienced in concussion management 3

Management of Persistent Symptoms (Beyond 10 Days)

Implement multidisciplinary management including: 3, 4

• Formal neuropsychological assessment 3, 4
• Graded physical exercise programs 3, 4
• Vestibular rehabilitation if indicated 4
• Psychological treatment if needed 3, 4

Approximately 15-20% of adolescents develop persistent post-concussion syndrome. 3, 4

Expected Recovery Timeline

Most adolescents recover within 7-10 days, though cognitive recovery often takes longer than symptom resolution in this age group. 1, 3

Critical Pitfalls to Avoid

Prolonged strict rest beyond 3 days is detrimental - it worsens outcomes, delays recovery, and may contribute to physical deconditioning and psychological consequences. 1, 2, 4, 5

High-intensity physical activity during recovery is harmful - exercise must remain below symptom threshold. 2, 3

Same-day return to play is never appropriate, even if asymptomatic. 1, 3

Returning to activity while taking symptom-controlling medications indicates incomplete recovery. 1, 3

Rationale for Early Active Rehabilitation

The evidence strongly supports early introduction of sub-threshold aerobic exercise in adolescents after the initial 24-48 hour rest period. 1 Two high-quality randomized controlled trials specifically in adolescents demonstrated that aerobic exercise is appropriate therapy for acute concussion. 1 Conversely, prolonged rest creates an "activity restriction cascade" that may contribute to physical deconditioning, removal from validating life activities, and persistence of post-concussive symptoms. 5