What is the appropriate management for a cerebral concussion?

Management of Cerebral Concussion

The cornerstone of concussion management is immediate removal from activity followed by cognitive and physical rest, with a graded return-to-activity protocol initiated only after complete symptom resolution. 1

Immediate Management

Recognition and Removal from Activity

• Remove the patient immediately from play or activity if concussion is suspected – even a "ding" or low-grade concussion requires immediate cessation of activity, as the outdated practice of returning athletes after 15 minutes is dangerous and increases risk of long-term complications. 1
• Rule out more severe intracranial injury through detailed history and physical examination, looking specifically for signs of skull fracture, focal neurological deficits, or deteriorating mental status. 1, 2
• Assess for cervical spine injury before proceeding with further evaluation. 3

Initial Assessment

• Evaluate using a systematic approach that includes symptom assessment, neurocognitive testing, and balance evaluation – headache is the most common presenting symptom. 3, 4
• Use validated sideline assessment tools and symptom checklists to document baseline severity across multiple domains: physical (headache, dizziness), cognitive (confusion, memory problems), mood (anxiety, irritability), and sleep disturbances. 1, 2, 5
• Assess specifically for vestibular symptoms in pediatric patients, as this subtype is highly prevalent and requires early targeted rehabilitation. 1

Acute Management (First 72 Hours)

Rest Protocol

• Prescribe both cognitive and physical rest as the primary treatment – this means limiting screen time, reading, schoolwork, and all physical activities that provoke symptoms. 1
• Provide education and reassurance to patients and families that symptoms are typically short-lived and correlate to physiologic changes that resolve with appropriate rest. 5

Symptom-Specific Management

• Evaluate for and address anxiety, mood disturbances, and sleep problems even in the acute setting, as up to one-third of patients exhibit these symptoms immediately post-injury. 1
• Implement sleep hygiene counseling and consider pharmacologic management if sleep disturbance is significant. 1
• For patients with prominent vestibular symptoms (dizziness, balance problems), prescribe early vestibular rehabilitation strategies to facilitate timely recovery. 1

Monitoring

• Monitor closely for any worsening symptoms, persistent vomiting, severe headache, or neurological deterioration that would warrant urgent neuroimaging. 1, 2
• Use validated symptom scales and neurocognitive testing to objectively track recovery trajectory. 3, 4, 5

Return-to-Activity Protocol

Timing

• Do not initiate return-to-activity until the patient is completely asymptomatic at rest – rigid classification systems have been abandoned in favor of individualized assessment. 3, 5
• Children and adolescents require a more conservative approach with longer recovery periods, as their developing brains may be more susceptible to concussion effects. 1, 3
• Patients with history of previous concussions also require extended recovery time. 3

Graded Progression

• Implement a progressive, stepwise return-to-activity protocol with close supervision at each stage: 1

  1. Light aerobic exercise (walking, stationary cycling)
  2. Sport-specific exercise without contact
  3. Non-contact training drills
  4. Full-contact practice
  5. Return to competition

• If any symptoms return at any stage, immediately drop back to the previous asymptomatic level and allow additional recovery time before re-attempting progression. 1

• Each stage should last a minimum of 24 hours, meaning the fastest possible return is 5 days after becoming asymptomatic. 1

Return to Learn

• Coordinate return-to-school protocols simultaneously with return-to-play, as cognitive symptoms can interfere with academic performance. 1, 6
• Implement academic accommodations (extended time, reduced workload, frequent breaks) as needed during recovery. 6

Special Considerations

Pediatric and Adolescent Athletes

• Use extra caution in young athletes – their brains are still developing and may be more vulnerable to both acute effects and long-term complications. 1
• Never allow the misconception that concussion can be "toughed out" – all suspected concussions require medical evaluation. 1

Prolonged Symptoms

• If symptoms persist beyond expected recovery timeframe (typically 7-10 days for adults, potentially longer for children), conduct further diagnostic evaluation and consider referral to concussion specialists. 5, 6
• Neuropsychological testing is a helpful tool in managing complicated cases. 1

Critical Pitfalls to Avoid

• Never allow same-day return to play – even if symptoms resolve quickly, the brain remains vulnerable to second-impact syndrome. 1
• Do not rely solely on patient self-report, as athletes may underreport symptoms to expedite return to play, increasing risk of persistent symptoms and future concussions. 1
• Avoid premature return to cognitive activities (school, work, screens) as this can prolong recovery. 1
• Do not use rigid grading systems or fixed timelines – recovery is highly variable and must be individualized. 3, 5