What is the appropriate management and treatment for a patient with a concussion?

Concussion Management

For acute concussion, implement 24-48 hours of moderate physical and cognitive rest, then immediately begin supervised, sub-threshold aerobic exercise—particularly in adolescents where this approach has the strongest evidence—while avoiding both prolonged rest beyond 3 days and premature return to high-risk activities. 1, 2

Immediate Management (First 24-48 Hours)

Remove from play immediately when concussion is suspected—"when in doubt, sit them out"—and never allow same-day return to activity even if symptoms resolve. 1, 2

Initial Rest Period

• Implement moderate physical and cognitive rest for 24-48 hours only to allow initial brain recovery. 1, 3
• Physical rest includes no sports, exercise, or strenuous activity that significantly increases heart rate. 2
• Cognitive rest includes limiting screen time, reducing academic workload, and avoiding activities requiring intense concentration. 2
• Critical pitfall: Do not prescribe strict rest exceeding 3 days, as prolonged rest actually worsens outcomes and delays recovery. 2, 4, 5

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
• Seizure activity
• Focal neurological deficits
• Visual changes or signs of basilar skull fracture

Gradual Return to Activity (After 48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial 24-48 hour rest period—this is the only intervention with strong evidence as appropriate therapy, particularly for adolescents with acute concussion. 6, 2

Exercise Protocol

• Start with light aerobic exercise (walking, swimming, stationary cycling) that stays below the symptom-exacerbation threshold. 1, 3
• The evidence is strongest for adolescents: Two high-quality RCTs with low-to-moderate risk of bias conclusively demonstrate that aerobic exercise is appropriate therapy for adolescents with acute concussion. 6
• For other age groups (children and adults), the panel remains uncertain whether exercise is appropriate due to insufficient quality evidence. 6
• Introduce activities gradually with close monitoring of symptom number and severity. 1, 3

Stepwise Progression

Each step requires a minimum of 24 hours and complete symptom resolution before advancing: 1, 2

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

If symptoms recur at any step, return to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 1

Return to School/Cognitive Activities

• Gradually increase academic activities as tolerated, beginning soon after the initial rest period. 1, 3
• Implement temporary accommodations if symptoms interfere with performance: shortened school days, reduced workloads, extended time for assignments and tests, and breaks as needed. 1, 2
• Customize return-to-school protocols based on symptom severity. 3

Return to Full Activity Criteria

Allow return to full activity only when the patient: 1, 2

• Has returned to premorbid performance level
• Remains completely symptom-free at rest
• Shows no symptom recurrence with increasing physical exertion
• Has received medical clearance from a physician experienced in concussion management

Critical restriction: Do not clear for return to play if the patient is taking any medications for concussion symptoms. 2

Management of Persistent Symptoms (Beyond 10 Days)

Approximately 15-20% of concussion patients develop persistent post-concussion syndrome. 6, 2

Multidisciplinary Approach

Implement multidisciplinary management for symptoms persisting beyond 10 days, including: 1, 2

• Formal neuropsychological assessment for persistent cognitive symptoms
• Graded physical exercise programs
• Vestibular rehabilitation
• Manual therapy for cervical spine issues
• Psychological treatment
• Oculomotor vision treatment

Essential Assessment

Assess for preexisting, coexisting, and resulting comorbidities, as persisting symptoms are often attributable to factors beyond the concussion itself. 6

• Preexisting mood disorders and high initial symptom load are the most consistent predictors of prolonged symptoms in youth athletes. 6
• Screen for learning disabilities, ADHD, and migraine headaches, which complicate diagnosis and management. 2

Evidence Quality and Nuances

The 2023 PM&R consensus statement—the most comprehensive recent guideline—found mixed evidence for most interventions: 6

Rest Evidence

• Strict rest and intense physical activity were found to be either ineffective or detrimental in randomized controlled trials, despite showing benefit in small retrospective studies. 6
• The panel concluded they are uncertain whether physical rest, cognitive rest, or combined rest is appropriate for acute concussion due to moderate-to-high risk of bias in studies. 6
• Randomized trials demonstrated either negative results or detrimental effects of combined cognitive/physical rest. 6

Exercise Evidence

• Two high-quality RCTs specifically in adolescents provide the strongest evidence supporting aerobic exercise as appropriate therapy. 6
• For chronic concussion, evidence is inconclusive—many studies showed benefit but lacked control groups and evaluated exercise as part of multimodal strategies. 6

Special Population Considerations

Adolescents

• Manage more conservatively with stricter return-to-play guidelines than adults due to higher risk of catastrophic injury and longer recovery times. 2
• Most adolescents recover within 7-10 days, though some may take weeks to months. 2
• Exercise therapy has the strongest evidence specifically in this age group. 6, 2

Medication Use

• Limit medication to acetaminophen only, and only as recommended by a physician. 1, 2
• Avoid returning to play while taking any medications for concussion symptoms. 1, 2

Common Pitfalls to Avoid

• Returning to activity too soon, which worsens outcomes or prolongs recovery. 1
• Inadequate rest during the acute 24-48 hour phase. 1
• Excessive rest beyond 48-72 hours, which is counterproductive and may worsen outcomes. 1, 2, 4, 5
• Allowing high-intensity physical activity during recovery, which can be detrimental. 2, 3
• Relying solely on patient-reported symptoms without objective assessment tools. 2