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

Mild Concussion Treatment

For mild concussion, implement 24-48 hours of moderate physical and cognitive rest immediately after injury, followed by supervised, gradual return to activity with sub-threshold aerobic exercise as the primary evidence-based therapy, particularly in adolescents. 1, 2, 3

Immediate Management (First 24-48 Hours)

• Remove the patient from activity immediately—"When in doubt, sit them out"—and never allow same-day return to play even if symptoms resolve 1, 2, 3
• Implement moderate physical and cognitive rest for 24-48 hours to allow initial recovery during the acute neurometabolic cascade 1, 2, 3
• Physical rest includes avoiding sports, exercise, strenuous activities, and anything that significantly increases heart rate 3
• Cognitive rest includes limiting screen time, reducing academic workload, avoiding video games, computer use, television, loud music, and activities requiring intense concentration 2, 3
• Use only acetaminophen for symptom management if needed, avoiding NSAIDs/aspirin due to theoretical bleeding risk 2, 3
• Monitor for red flags requiring emergency evaluation: loss of consciousness, repeated vomiting, severe or worsening headache, altered mental status, seizures, focal neurological deficits, or visual changes 1, 2, 3

Critical Pitfall: Avoid Prolonged Rest

• Do not continue strict rest beyond 48-72 hours, as prolonged rest exceeding 3 days actually worsens outcomes and delays recovery 1, 2, 3, 4
• Excessive rest can lead to physical deconditioning, reactive depression, and paradoxically prolong postconcussive symptoms 5, 6, 4
• The evidence shows that both extremes—excessive exertion and prolonged avoidance of exercise—have negative consequences 7, 5

Gradual Return to Activity Protocol (After Initial 24-48 Hours)

Begin supervised, sub-threshold aerobic exercise after the initial rest period—this is the only intervention with strong evidence as appropriate therapy, particularly in adolescents. 1, 2, 3

Stepwise Progression:

1. Light aerobic exercise: Walking, swimming, or stationary cycling that stays below the symptom-exacerbation threshold 1, 2, 3
2. Sport-specific exercise: Skating drills in hockey, running drills in soccer (no 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: Final step 1, 2

Protocol Rules:

• Each step requires a minimum of 24 hours before advancing to the next level 1, 2, 3
• Patient must be completely symptom-free at each level before progression 1, 2, 3
• If symptoms recur during any step, return to the previous asymptomatic level and rest for 24 hours before attempting progression again 1, 2, 3
• Exercise should be supervised and remain below the symptom-exacerbation threshold 1, 6

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated after the initial 24-48 hour rest period 1, 3
• Implement temporary accommodations if symptoms interfere with academic performance: shortened school days, reduced workload, extended time for assignments and tests, breaks during the day as needed 1, 3
• Avoid complete withdrawal from school, as prolonged removal from validating life activities contributes to persistent symptoms 5

Return to Full Activity Criteria

Allow return to full activity only when all three criteria are met: 1, 2, 3

• Patient has returned to premorbid performance level
• Remains completely symptom-free at rest
• Shows no symptom recurrence with increasing physical exertion

Additional Requirements:

• Do not clear for return to play if the patient is taking any medications for concussion symptoms, as this indicates incomplete recovery 2, 3
• Obtain medical clearance from a physician experienced in concussion management 3

Management of Persistent Symptoms (Beyond 10 Days)

• Implement multidisciplinary management for symptoms persisting beyond 10 days, as approximately 15-20% of patients develop persistent post-concussion syndrome 1, 2, 3
• Treatment modalities include: 1, 2
  • Graded physical exercise programs (primary intervention)
  • Vestibular rehabilitation for vestibular dysfunction
  • Manual therapy for cervical spine/neck pain
  • Vision therapy for oculomotor problems
  • Cognitive behavioral therapy
  • Formal neuropsychological assessment for persistent cognitive symptoms
• Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks 2

Special Considerations for Adolescents

• Exercise therapy has the strongest evidence specifically in adolescents, making it the cornerstone of management in this age group 3, 6
• Manage pediatric and adolescent athletes more conservatively with stricter return-to-play guidelines than adults, as recovery may take longer and they face higher risk of catastrophic injury 1, 3
• Most teenagers recover within 7-10 days, though some may take weeks to months 3

Common Pitfalls to Avoid

• Never allow same-day return to play, even if asymptomatic 1, 2, 3
• Avoid strict rest beyond 48-72 hours, as this is counterproductive and can worsen outcomes 1, 2, 3, 4
• Do not use vestibular suppressants (antihistamines like meclizine, benzodiazepines) routinely, as they provide no benefit and may interfere with central compensation mechanisms 2
• Avoid high-intensity physical activity during recovery, as this can be detrimental 1, 2
• Do not rely solely on patient-reported symptoms without objective assessment 2, 3
• Never return to play while taking medications for concussion symptoms 1, 2, 3

Evidence Quality Note

The 2023 consensus statement found that most concussion treatment studies were of moderate to high risk of bias, with mixed results limiting definitive conclusions 8, 3. However, the evidence consistently supports: (1) brief initial rest of 24-48 hours, (2) avoidance of prolonged rest beyond 3 days, and (3) supervised sub-threshold aerobic exercise as the primary evidence-based intervention, particularly in adolescents 8, 1, 2, 3, 6, 4.