Concussion Management in Adolescents

Initial Management

• The American Academy of Pediatrics recommends relative rest, including both physical and cognitive activity, for the first 24-48 hours after injury, followed by a gradual schedule of activity that doesn't exacerbate symptoms, rather than strict bed rest until complete symptom resolution 1
• A person with signs and symptoms of a concussion should be immediately removed from activity and not allowed to return until evaluated by a healthcare professional, with an initial period of relative rest for 24-48 hours followed by a graded return to activity protocol, as recommended by the American Heart Association and the American Academy of Neurology 2, 1
• Exercise is recommended as an appropriate therapy for adolescents with acute concussion after 24-48 hours of relative rest, while strict bed rest and high-intensity physical activity should be avoided, as recommended by the American Academy of Physical Medicine and Rehabilitation 3

Recovery and Return to Play

• Recovery is typically longer in adolescents than in college/professional athletes, lasting 7-10 days or longer 4
• The American Academy of Pediatrics recommends that athletes should not return to play on the same day as the concussion, even if symptoms resolve 4
• A 5-stage graded return to activity protocol is recommended, with each stage lasting a minimum of 24 hours, and progressing to the next stage only if asymptomatic at the current stage, as outlined in the table:

5, 3, 1, 6

• If symptoms return during any stage, stop activity immediately, rest for at least 24 hours, and resume at the previous asymptomatic level, as recommended by the American Academy of Pediatrics 4
• The minimum recovery time is 5 days to progress through the protocol to resume full activity, provided symptoms do not return, as recommended by the American Academy of Pediatrics 4
• Require medical clearance from a licensed healthcare provider trained in concussion management before full return to play, as stated by the American Academy of Pediatrics 1

Post-Concussion Syndrome

• The American Academy of Pediatrics recommends monitoring for post-concussion syndrome if symptoms persist beyond 4-6 weeks 1
• Post-concussion syndrome requires targeted interventions for specific persistent symptoms, including graded physical exercise, vestibular rehabilitation, manual therapy, psychological treatment, vision therapy, and cognitive rehabilitation, through an interdisciplinary approach, as defined by the World Health Organization (WHO) and recommended by the American College of Sports Medicine 7, 4, 8

Special Considerations

• School performance may be significantly affected by concussion and requires appropriate accommodations 4
• Headache is the most frequently reported symptom of concussion in children, followed by dizziness, fatigue, and difficulty with concentration, with other symptoms including nausea/vomiting, balance problems, light sensitivity, noise sensitivity, and visual problems 4
• Loss of consciousness occurs in less than 10% of concussions, and if present for more than 30 seconds, may indicate more significant injury, while amnesia can be an important indicator of potentially more serious injury 4
• Concussion is a clinical diagnosis based on history of mechanical force to the head, presence of symptoms such as confusion/disorientation, loss of consciousness (≤30 minutes), post-traumatic amnesia (<24 hours), transient neurological abnormalities, and Glasgow Coma Scale score of 13-15, as defined by the American Academy of Neurology 1
• A comprehensive concussion assessment should evaluate all five concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) as well as associated conditions like sleep disturbance to properly characterize the injury and guide appropriate management, as recommended by the American Academy of Neurology 8
• Athletes who are symptomatic at rest and after exertion for at least 20 minutes should not return on the day of injury, and those experiencing loss of consciousness or amnesia should be disqualified from further participation on the day of injury, as recommended by the American Academy of Neurosurgery 5
• Athletes with a history of concussion should be treated more conservatively, and consideration should be given to temporary or permanent disqualification from contact sports for those with three or more concussions and slowed recovery, as recommended by the American Academy of Neurosurgery 5

Medication and Treatment

• The American Academy of Neurosurgery recommends using acetaminophen as the preferred medication for headache management, and avoiding medications except acetaminophen unless specifically recommended by a physician, and instructing patients to avoid alcohol, illicit drugs, and other substances that might interfere with cognitive function and recovery 5
• For post-concussion headaches, acetaminophen (1000 mg) or ibuprofen (400 mg) should be used as first-line treatment, with careful monitoring for analgesic overuse that can lead to rebound headaches, as recommended by the American Academy of Pediatrics and the American College of Physicians 9, 1
• Clear discharge instructions about warning signs and when to seek emergency care should be provided to patients and families, and consider referral to a concussion specialist for complex cases or persistent symptoms, as recommended by the American College of Emergency Physicians and the American Academy of Pediatrics 10, 3, 1