The acute symptomatic phase is defined as the time from injury, through maximum symptoms, to the beginning of when the symptoms resolve. Typically, this phase lasts less than three days. If you experience any of the following "Red Flag Symptoms during this phase," you should go to the emergency room:

• Loss of consciousness for more than one minute
• Increasing confusion or inability to stay awake
• Repetitive vomiting
• Seizure or convulsion
• Severe or increasing headache
• Severe neck pain
• Weakness, tingling, or burning in arms or legs
• Persistent double vision or loss of vision
• Increasingly restless, agitated, or combative

In the first one to two days after suffering a concussion, near complete rest is important.

Even though symptoms during the acute symptomatic phase may be quite limiting, returning to light thinking and physical activities should start after the first couple of days. 

Examples of light thinking activity include:

• Watching TV
• Pleasure reading (if tolerated)
• Listening to music
• Short periods of schoolwork

Examples of light physical activity include:

• Light chores around home
• Short walks

During the acute symptomatic phase, it is typical that thinking and physical activity can make symptoms worse. Exposure to bright lights, loud sounds, and movement may also worsen symptoms. During the acute symptomatic phase, any activity that worsens symptoms should be avoided or limited. 

Management During the Acute Symptomatic Phase

During the first 24 hours you should avoid medications that can increase risk of bleeding. These include aspirin, ibuprofen (Advil), and naproxen sodium (Naprosyn, Aleve). During the first 24 hours acetaminophen (Tylenol) can be used for pain relief. After the first 24 hours, ibuprofen (Advil) and naproxen sodium (Naprosyn, Aleve) are generally more effective for pain relief, and are safe. In some patients, nausea and vomiting can be bothersome, and prescription medications can help.

Restful sleep is important in all stages of recovery from concussion. If getting to sleep or staying asleep is difficult, discuss this with your doctor for further recommendations. Sleep behavior techniques may be helpful as is the use of certain medications.

Throughout concussion recovery you should be sure to stay hydrated (60-80 ounces of water or non-caffeinated beverages per day), and eat normally.

The recovery phase is characterized by:

• Lessening symptoms
• Ability to perform more intense thinking and physical activities without symptoms getting worse
• Gradual return to your preinjury state

During this phase it is common that symptoms will worsen with more thinking and physical activity. 

Gradual Return to Thinking and Physical Activity

After a 1-2 day period of rest, gradually increasing thinking and physical activity should be encouraged. During the recovery phase, symptoms should gradually improve to the point where you are symptom-free at rest, first with thinking activities, and then with physical exertion.

The amount of thinking and physical activity that is tolerated during recovery from concussion is dynamic and based on symptoms. Until recently, the recommendation had been to rest until symptom-free. New studies, including one performed at Michigan NeuroSport, suggest that limited exercise during the recovery phase allows for quicker recovery from concussion. 

Return to physical activity and exercise should be gradual and determined by your doctor. 

Examples of cardiovascular exercises that are started during this phase include use of a stationary bike or walking. Again, the specifics of the activity should be determined and guided by your doctor. Exercises that require bearing down, such as situps, pushups, pullups and weight lifting, should be avoided at first unless directed by your doctor, as they typically worsen symptoms.

Determining what type and how much activity is part of an individualized care plan that should be provided by your clinic. Accommodations may be needed during the transition to full-time school and work.

Academic Accommodations Following Concussion

• Notify school of concussion
• Develop plan for gradual return-to-school demands
• Provide waiver of missed assignments or exams
• Plan to assist/support completion of missing assignments
• Provide rest time/breaks during school day
• Consider exemption from upcoming standardized tests
• Excuse activities requiring rigorous physical activity
• Reduce homework assignments
• Reschedule, coordinate or pace exams during times when the student is asymptomatic
• Negotiate timing of large assignments
• Assign a counselor
• Preferential seating for nose reduction and teaching monitoring
• Allow test-taking in a distraction-free environment
• Allow extended time for exams and assignments
• Using dedicated notetaker

Adapted from O'Neil JA, Cox MK, Clay OJ, et al. A review of the literature on pediatric concussions and return-to-learn (RTL): Implications for RTL policy, research, and practice. Rehabilitation Psychology: 2017;62(3):300-323

Management During the Recovery Phase

During the recovery phase factors that are causing symptoms should be sought and treatment plans put in place for their resolution. Common treatable causes of concussion-like symptoms include; neck injury, dizziness, lightheadedness, vision problems, difficulty with sleep, and new or worsening mood symptoms.  Continued follow up at a clinic with expertise in management of concussion during the recovery phase allows for an individualized recovery plan including, a prescription for exercise and referrals to optimize recovery.

During the symptomatic/recovery phase use of medications may still be necessary. Consistent scheduled medications used to treat headache should be discouraged, and reserved for severe headaches that limit activities. Consistent, prolonged use of medications to treat headache may result in medication overuse or rebound headache.

Medications for nausea may also be considered, if nausea is severe. During this phase nausea should significantly improve, and if it doesn't, alternative explanations for it should be sought.

Recovery is influenced by several important factors. Normal recovery for those younger than 18 is considered 30 days, and for those older than 18 is considered 14 days. A goal of recovery management it to avoid prolonged recovery, but 10-30% of those experiencing concussion can experience prolonged recovery.

The dynamic nature of concussion recovery requires follow-up with tailored management during each phase of concussion. Key milestones in the recovery process are return to learn, school, work, exercise, and sport. Each of these milestones is approached gradually from symptom-limited activity to full participation.

Symptoms Associated With (or Not Associated With) Prolonged Concussion Recovery

Factors associated with prolonged recovery:

• Initial symptom burden
• Female gender
• Age less than 18, with ages approximately 13-17 being at highest risk for prolonged recovery
• History of mental health issues
• Concurrent cervical involvement
• Convergence insufficiency

Factors not consistently assocated with prolonged recovery:

• History of migraine
• History of a neurobehavioral or attention disorder, i.e. ADHD or ADD
• Loss of consciousness

Adapted from Iverson GL, Gardner, AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine, 2017;51(12):941.