Concussion Management Protocol

Initial Management

The American Academy of Pediatrics recommends implementing moderate physical and cognitive rest for the first 24-48 hours after concussion to allow initial recovery 1, 2
Avoid strict prolonged rest (exceeding 3 days) as this can actually worsen outcomes 1
Remove the individual from play immediately if a concussion is suspected - "When in doubt, sit them out!" 2
Monitor for warning signs requiring immediate medical attention: loss of consciousness, severe or worsening headache, repeated vomiting, altered mental status, seizures, visual changes 3, 2

Begin gradual reintroduction of activities that do not worsen symptoms after the initial 24-48 hour rest period 1
Implement a progressive schedule with close monitoring of symptom expression (number and severity) 1
Introduce supervised, non-contact aerobic exercise that stays below symptom-exacerbation threshold 1
Each step in the return to activity protocol should take a minimum of 24 hours 2
If symptoms recur during the protocol, return to the previous asymptomatic level and try to progress again after 24 hours of rest 3, 2

Gradually increase duration and intensity of academic activities as tolerated 1, 2
Implement appropriate educational accommodations if symptoms interfere with academic performance 2
Temporary accommodations may include shortened school days, reduced workloads, extended time for assignments and tests 2

Follow a stepwise return to play protocol that typically includes:
Do not return to play while taking any medications for concussion symptoms 2
Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion 1

Implement multidisciplinary management for symptoms persisting beyond 10 days 2
Recognize that 15-20% of concussion patients develop persistent post-concussion syndrome 3, 2
Consider formal neuropsychological assessment for patients with persistent cognitive symptoms 2
A multidisciplinary approach may include graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, and oculomotor vision treatment 3

Recovery may take longer in younger athletes compared to older ones; manage more conservatively with stricter return-to-play guidelines 2
Older patients often experience concussions from low-velocity mechanisms such as falls from standing height 3
Avoid high-intensity physical activity during recovery as this can be detrimental 1
Medication use should be limited to acetaminophen only, and only as recommended by a physician 3, 2

Returning to activity too soon, which can worsen outcomes or prolong recovery 2
Inadequate rest during the acute phase (first 24-48 hours) 2
Excessive rest beyond the initial 24-48 hours, which can be counterproductive 1
Relying solely on patient-reported symptoms without objective assessment 2
Inconsistent online resources that may provide conflicting information about concussion management 4

The American Academy of Physical Medicine and Rehabilitation recommends graded physical exercise programs as the primary intervention for managing persistent post-concussion syndrome, with approximately 15-20% of patients developing this condition 5
The American Academy of Physical Medicine and Rehabilitation suggests vestibular rehabilitation for vestibular dysfunction in patients with persistent post-concussion syndrome 5
The American Academy of Physical Medicine and Rehabilitation proposes manual therapy for cervical spine/neck pain in patients with persistent post-concussion syndrome 5
The American Academy of Physical Medicine and Rehabilitation recommends cognitive behavioral therapy for patients with persistent post-concussion syndrome 5
The American Academy of Physical Medicine and Rehabilitation advises formal neuropsychological assessment for persistent cognitive symptoms in patients with post-concussion syndrome 5

The 2023 consensus statement found that most concussion treatment studies were of moderate to high risk of bias, with mixed results limiting definitive conclusions, but consistently supports brief initial rest, avoidance of prolonged rest, and supervised sub-threshold aerobic exercise as the primary evidence-based intervention, particularly in adolescents 5