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

Concussion Management

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 treatment—avoid prolonged rest beyond 48-72 hours as this worsens outcomes and delays recovery. 1, 2

Immediate Assessment and Management

Remove the patient from activity immediately when concussion is suspected—never allow same-day return to play, even if symptoms completely resolve. 1, 2

Red Flags Requiring Emergency Evaluation:

• Loss of consciousness or altered mental status 1, 2
• Severe or worsening headache, especially with repeated vomiting 1, 3
• Seizure activity or focal neurological deficits 1, 2
• Signs of basilar skull fracture 2
• GCS score <15 at any point 2

Initial Rest Period (First 24-48 Hours):

• Physical rest: No sports, exercise, or activities that significantly increase heart rate 2
• Cognitive rest: Limit screen time, reduce academic workload, avoid activities requiring intense concentration 2
• Pain management: Use acetaminophen 650-1000 mg every 4-6 hours or ibuprofen 400-800 mg every 6 hours as needed 3
• Critical warning: Do not use pain medication more than 2-3 days per week—this causes rebound headaches that worsen the condition 3

Gradual Return to Activity Protocol (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, particularly in adolescents. 1, 2 Prolonged strict rest beyond 48-72 hours is counterproductive and actually worsens outcomes. 1, 2

Stepwise Progression (Minimum 24 Hours Per Step):

1. Light aerobic exercise: Walking, swimming, stationary cycling below symptom threshold 1, 2
2. Sport-specific exercise: Running drills, skating drills without 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: When completely symptom-free with exertion 1, 2

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 Play Criteria:

• Complete symptom resolution at rest 1, 2
• No symptom recurrence with increasing physical exertion 1, 2
• Return to premorbid performance level 1, 2
• Not taking any medications for concussion symptoms 1, 2
• Medical clearance from physician experienced in concussion management 2

Return to School/Cognitive Activities

Gradually increase academic activities as tolerated, implementing temporary accommodations if symptoms interfere with performance. 1, 2

Academic Accommodations:

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

Most patients recover within 7-10 days, though some may take weeks to months. 2

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

Multidisciplinary Interventions:

• Graded physical exercise programs: Primary intervention recommended by the American Academy of Physical Medicine and Rehabilitation 1
• Vestibular rehabilitation: For vestibular dysfunction 1
• Manual therapy: For cervical spine/neck pain 1
• Cognitive behavioral therapy: For psychological symptoms 1
• Formal neuropsychological assessment: For persistent cognitive symptoms 1
• Tricyclic antidepressants (e.g., amitriptyline): May be considered for chronic postconcussion headache 3

Refer to a specialist in traumatic brain injury if symptoms persist beyond 3 weeks. 3

Special Population Considerations

Manage pediatric and adolescent athletes more conservatively with stricter return-to-play guidelines than adults—recovery takes longer in younger athletes and they have higher risk of catastrophic injury. 1, 2 Exercise therapy has the strongest evidence specifically in adolescents. 1, 2

Older patients often experience concussions from low-velocity mechanisms such as falls from standing height. 1

Critical Pitfalls to Avoid

• Returning to activity too soon: Increases risk of persisting symptoms and future concussion 1
• Prolonged rest beyond 48-72 hours: Actually worsens outcomes and delays recovery—this is a common mistake 1, 2, 4
• Analgesic overuse: Using pain medication more than 2-3 days per week causes rebound headaches 3
• Relying solely on patient self-report: Underreporting leads to premature return to activity; overreporting leads to prolonged unnecessary rest 5
• Dismissing severe headache: May miss life-threatening intracranial complications requiring imaging 3
• Allowing same-day return to play: Never permit this, even if symptoms completely resolve 1, 2