The correct answer is:

Recommend a day or two of physical and cognitive rest, followed by introduction of activities that don’t worsen symptoms

Key Point:

Initially, recommend a day or two of relative physical and cognitive rest, then gradually reintroduce low-intensity aerobic activities and cognitive activities that don't exacerbate symptoms

Explanation:

Mild traumatic brain injury (mTBI) is the term that the WHO recommends to encompass concussion.

An mTBI is defined as an acute brain injury resulting from physical forces that includes confusion, disorientation, amnesia, or other transient neurological abnormalities, provided that the Glasgow Coma Score (GCS) is 13-15, thirty minutes post-injury.

The incidence of mTBI is highest in sports like rugby, football, hockey, lacrosse and soccer.

An athlete who sustains mTBI should be immediately removed from play and evaluated on the sidelines. Once cervical spine injury or more serious head injury is ruled out, the athlete should be evaluated using a standardized mTBI evaluation instrument such as the Standardized Assessment of Concussion (SAC) or the Sport Concussion Assessment Tool 5 (SCAT5).

Neuroimaging is not required in all cases of mTBI, and should be used selectively, given the known risks of ionizing radiation. In this case, though the athlete has continued symptoms, there are not high-risk symptoms such as seizure, prolonged loss of consciousness, vomiting or worsening headache to indicate a need for CT scan.

Historically, prolonged rest had been recommended after concussion and concussions were also graded in severity, depending partially on whether there was any loss of consciousness. Now, it is known that loss of consciousness and concussion severity are not tightly linked. Current evidence also shows that prolonged physical and cognitive rest are not helpful, and, in fact, prolong the duration of symptoms.

The most recent recommendations for mTBI/concussion management suggest a brief period (one to two days) of rest, followed by introduction of activities such as light aerobic exercise, if they don’t worsen symptoms. Then, further activities are introduced in stepwise fashion, if symptoms are not worsened by the activity.

There are five recommended steps of increased activity, and each is supposed to last at least 24 hours, with a return to prior step if any symptom worsening, meaning that there will be at least five days from concussion to return to play.

At the end of the return-to-play steps, the athlete can return to play, once they have no symptoms at rest or with activity.

Figures:

Concussion: Youth Sports Concussion Case MRI

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References:

Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853

Halstead ME, Walter KD, Moffatt K, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report--sport-related concussion in children and adolescents. Pediatrics 2018; 142:e20183074

Leddy JJ, Haider MN, Hinds AL, et al. A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med 2018

Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015; 135:213