What is the best approach to managing a patient with a concussion?

Concussion Management Approach

Implement 24-48 hours of moderate physical and cognitive rest immediately after concussion, then begin supervised sub-threshold aerobic exercise as the primary evidence-based therapy, avoiding both strict prolonged rest beyond 3 days and high-intensity activity. 1, 2

Immediate Assessment and Removal from Activity

• Remove the patient from play immediately when concussion is suspected—"When in doubt, sit them out!" 1, 3
• Never allow same-day return to play, even if symptoms completely resolve 3, 2
• Assess for red flags requiring emergency evaluation: loss of consciousness, altered mental status, repeated vomiting, severe or worsening headache, seizures, focal neurological deficits, or signs of skull fracture 1, 3, 2
• Evaluate concurrently for cervical spine injury, as concussion mechanism often involves neck trauma 2

Acute Phase Management (First 24-48 Hours)

Physical Rest:

• No sports, exercise, or strenuous physical activity 2
• Avoid activities that significantly increase heart rate 2
• No contact or collision activities 2

Cognitive Rest:

• Limit screen time (phones, computers, television) 2
• Reduce academic workload 2
• Avoid activities requiring intense concentration 2

Medication Guidelines:

• Use only acetaminophen for symptom management, and only as recommended by a physician 4, 3, 2
• Avoid all other medications, alcohol, and illicit drugs that might interfere with neurological recovery 4

Critical Pitfall: Avoid Prolonged Rest

• Do not prescribe strict rest beyond 48-72 hours, as prolonged rest (>3 days) actually worsens outcomes and delays recovery 2, 5, 6
• Excessive rest leads to physical deconditioning, reactive depression, and prolonged symptoms 5, 6
• After the initial 24-48 hour period, begin gradual reintroduction of activities that do not worsen symptoms 1

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

Supervised Sub-Threshold Aerobic Exercise:

• Begin supervised aerobic exercise that stays below the symptom-exacerbation threshold 1, 2
• This is the only intervention with strong evidence as appropriate therapy, particularly in adolescents 4, 2
• Exercise should be voluntary and controlled, not forced or high-intensity 5

Stepwise Progression (Minimum 24 Hours Per Step):

1. Light aerobic exercise: Walking, swimming, or stationary cycling at low intensity 1, 2
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: Full unrestricted play 1, 2

Progression Rules:

• If symptoms recur at any step, return to the previous asymptomatic level and rest for 24 hours before attempting to progress again 1, 3
• Each step requires complete symptom resolution before advancing 2
• Monitor symptom number and severity closely throughout progression 1

Return to School/Cognitive Activities

• Gradually increase duration and intensity of academic activities as tolerated 1, 3
• Implement temporary accommodations if symptoms interfere with performance: 3, 2
  • Shortened school days
  • Reduced workloads
  • Extended time for assignments and tests
  • Postponement of standardized testing
  • Breaks during the day as needed

Criteria for Full Return to Activity

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

• Taking any medications for concussion symptoms
• Persistent symptoms at rest
• Symptoms recur with exertion

Clear for return only when: 1, 3

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

Management of Persistent Symptoms (>10 Days)

• Approximately 15-20% of patients develop persistent post-concussion syndrome 1, 3
• Implement multidisciplinary management including: 1, 3, 7
  • Formal neuropsychological assessment for persistent cognitive symptoms
  • Graded physical exercise programs (primary intervention)
  • Vestibular rehabilitation for vestibular dysfunction
  • Manual therapy for cervical spine/neck pain
  • Cognitive behavioral therapy for psychological symptoms
  • Oculomotor vision treatment if indicated

Special Population Considerations

Pediatric and Adolescent Athletes:

• Manage more conservatively with stricter return-to-play guidelines 2
• Recovery typically takes longer than in adults (most recover within 7-10 days, but some take weeks to months) 2
• Exercise therapy has the strongest evidence specifically in this age group 4, 2
• Higher risk of catastrophic injury with premature return 2

Common Pitfalls to Avoid

• Returning to activity too soon, which worsens outcomes and prolongs recovery 3
• Prescribing strict rest beyond 48-72 hours, which is counterproductive 2, 5
• Allowing high-intensity physical activity during recovery, which can be detrimental 1
• Relying solely on patient-reported symptoms without objective assessment 2
• Clearing patients who are still taking medications for concussion symptoms 3, 2