Concussion in Youth Sport: A Rehab-Informed, Co-Managed Approach

As youth hockey and football seasons get underway in Manitoba, concussion is back on the minds of parents, coaches, and clinicians. The good news is that our understanding of how to manage these injuries has improved considerably over the past decade. The advice many families remember, sit in a dark room and do nothing until symptoms disappear, no longer reflects the best evidence. What follows is a plain-language overview of current thinking, written with an important qualifier: concussion in youth is a medically co-managed condition, and nothing here replaces assessment by a physician.

What a concussion is

A concussion is a form of traumatic brain injury caused by a direct or indirect force transmitted to the head. It is a functional disturbance rather than a structural one, which is why standard imaging is usually normal. Symptoms can include headache, dizziness, nausea, sensitivity to light or noise, difficulty concentrating, irritability, and sleep disturbance. The international consensus statement on concussion in sport, updated after the 2022 Amsterdam conference, remains the reference point clinicians work from.¹

Why prolonged strict rest fell out of favour

For years the standard recommendation was near-complete physical and cognitive rest until symptoms fully resolved. Current evidence does not support this. A short initial period of relative rest, generally the first 24 to 48 hours, is still sensible, but beyond that, prolonged rest can slow recovery and worsen mood, sleep, and deconditioning.² The updated approach favours a brief rest followed by a gradual, symptom-guided return to light activity.

The most striking evidence comes from studies of early aerobic exercise. In a randomised clinical trial of adolescents, individualised sub-symptom-threshold aerobic exercise, activity kept deliberately below the intensity that provoked symptoms, was associated with faster recovery than a stretching comparison.³ The key phrase is sub-symptom-threshold: the activity is light, carefully dosed, and stopped short of aggravating symptoms. This is not a licence to push through, and it is best guided by a clinician who can establish the right intensity. It is, in a sense, the concussion version of a principle we return to often: there are no bad exercises, only too much too soon.

The role of the neck and vestibular system

Not every lingering symptom after a head impact comes from the brain itself. The same force that causes a concussion often affects the neck and the balance (vestibular) system, and these can drive headaches, dizziness, and neck pain that persist after other symptoms settle. A randomised controlled trial found that combined cervical spine and vestibular rehabilitation reduced the time to medical clearance in athletes with persistent post-concussion symptoms.⁴ This is a good example of regional interdependence: the neck, the visual and balance systems, and the brain interact, and treating them together often works better than treating any one in isolation. Targeted rehabilitation of the neck and vestibular system is an area where rehab-focused clinicians can contribute meaningfully within a medical team.

Why co-management is non-negotiable

This is the part worth stating plainly. A chiropractor or other rehabilitation clinician does not unilaterally diagnose a concussion, decide it has resolved, or clear an athlete to return to contact. Those decisions belong within a medical framework, typically led by a physician, following a graduated return-to-sport and return-to-learn protocol. A rehab clinician's role is collaborative: helping to guide sub-threshold activity, addressing cervical and vestibular contributors, and communicating with the physician and family throughout. Return to learn generally takes priority over return to sport, and both progress in stepwise stages, with a return to any given stage only after the previous one is tolerated without a meaningful increase in symptoms.¹

Red flags: when to seek urgent care

Most concussions recover well, but some signs point to a more serious injury and warrant immediate emergency assessment. Seek urgent medical care if a young athlete shows any of the following after a head impact:

• Loss of consciousness, or increasing confusion or agitation
• Repeated vomiting
• A headache that steadily worsens
• Seizures or convulsions
• Weakness, numbness, or difficulty with coordination or speech
• Unequal pupils, double vision, or increasing drowsiness or inability to wake
• Neck pain or tenderness after the impact

When in doubt, an athlete should be removed from play and assessed. The old adage holds: if in doubt, sit them out. No game or practice is worth a second impact while the brain is still recovering.

The bigger picture

Youth concussion management has shifted from passive waiting to active, staged recovery, always inside a medically supervised structure. Early, carefully dosed activity, attention to the neck and vestibular system, and clear communication among physician, rehab clinician, family, and coach give young athletes the best path back to school and sport. Managing training and playing loads sensibly across a season also matters; our article on youth sport specialisation and injury looks at that side of long-term athlete health. At Boreal Spine & Sport, we work as one part of that co-managed team, never as a substitute for the physician's role.

References

1. Patricios JS, Schneider KJ, Dvořák J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695-711.
2. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
3. Leddy JJ, Haider MN, Ellis MJ, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr. 2019;173(4):319-325.
4. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294-1298.

Dr. Michael Minenna D.C., B.Sc., SFMA, FMS