Element	Recommendations	Comments
Cognitive rest	Avoid text messaging or video games	Avoid activities that require attention or concentration
	Limit television and computer use
	Decrease schoolwork
Physical rest	Avoid any physical activity that exacerbates symptoms (e.g., aerobic exercise, lifting weights, household chores, sexual activity)	Severe or worsening headache, persistent vomiting, or seizures may suggest a need for neuroimaging
Medications/interventions	Wear sunglasses for photophobia	There is poor evidence for use of medications for postconcussive symptoms; therefore, medication choices are the same for those without concussion
	Wear earplugs or noise canceling headphones for phonophobia
	Take medications to alleviate specific symptoms (e.g., nonsteroidal anti-inflammatory drugs, acetaminophen, or amitriptyline for persistent headaches; sleep aids, anxiolytics, selective serotonin reuptake inhibitors for depressive symptoms)
	Be aware that some medications may mask postconcussive symptoms
	Avoid acute use of nonsteroidal anti-inflammatory drugs if there is potential for intracranial bleeding
Transition back to school	Alert school personnel to injury, and initiate slow reintegration	Usually can be accomplished informally, but formal interventions may be required (e.g., IEP, 504 plan)
	Consider the following: forgiveness of missed assignments and more time to complete tests and schoolwork, standard breaks and rest periods as needed, decreased schoolwork, distraction-free work areas, note taker
	Avoid standardized testing during recovery
	Monitor carefully for two to three months after concussion for scholastic difficulties
Graded return to play	After rest and resolution of symptoms, athletes may progress through a return-to-play protocol; each of the following steps should take 24 hours: Nonimpact aerobic exercise Sport-specific exercise (nonimpact drills) Noncontact training drills Full contact practice Return to normal play	Patient must be symptom-free and medication-free before starting return-to- play protocol If any symptoms develop, activity should be stopped immediately; 24 hours after symptoms resolve, protocol may resume at the last step for which the athlete was asymptomatic
Higher-risk patients	Factors that may suggest prolonged recovery or caution for return to play: More than three symptoms at presentation Specific symptoms (i.e., fatigue, tiredness, or fogginess) Headache lasting more than 60 hours Loss of consciousness for more than 60 seconds Amnesia History of concussion Age younger than 18 years Comorbid conditions Medication use (psychotropic drugs, anticoagulants) Dangerous style of athletic play High-risk sport (contact, collision)	Consider multidisciplinary approach (e.g., referral to health care professional experienced in concussion management, formal neuropsychological testing, communication with coach and training staff)