According to the American Medical Society for Sports Medicine, the care of these athletes is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion [4]. In general, there is no specific treatment for concussion, but for children and adolescents, a more conservative approach should be considered [4], and children and adolescents who sustain a concussive brain injury should be closely monitored over time for the later appearance of neurobehavioral abnormalities [14].

The treatment is rest and vigilance until symptoms resolve and medically cleared. The rest should be physical and mental as well. It is wisely advised that after brain injury/concussion, there should be cognitive rest along with physical rest [4, 12, 13, 22]. The complete rest must be respected in the 24–48 h after the concussion [12]. There shall be special caution with the medication: sleeping pills, aspirin, anti-inflammatory drugs, and sedating pain killers shall not be prescribed, and alcohol is not permitted [12]. Paracetamol is allowed for the headache. Sometimes the player during the recovery period might still complain of dizziness, neck pain, and headaches, attributed to cervical spine and vestibular system involvement, justifying cervical spine and balance treatments [6].

Students with a concussion must be restricted from physical activity, sports, or playground activity in order to protect the student-athlete from sustaining another blow to the head with already more vulnerable brain and because physical activity can cause symptoms to worsen during the early stages of recovery [7]. The goal is to limit cognitive activity to a level that is tolerable and that does not exacerbate or cause the reemergence of symptoms [22]. Any mental exercise should be avoided in order to prevent any excessive strain on the neurometabolic processes in the brain [3] and that includes, but is not limited to, playing video/computer games; watching movies/TV; using the computer, the tablet, or the mobile phone; reading or writing; listening to loud music; making crosswords; and any activity that requires processing speed, new learning retention, and working memory [4, 13, 22]. Symptom exacerbation follows cognitive activity (cognitive exertion effect) [22] and that is why the cognitive rest during the period of recovery after a brain injury has been considered important [7, 29]. The increased cognitive activity is associated with longer recovery from concussion [30].

The medical team is always asked about the moment the player is coming back to sports, and predicting a prognosis would be very helpful. However, the recovery time is highly variable, ranges from days to weeks, and is not easily predicted at the time of injury [31]. It is important to have meaningful return-to-play criteria [21], and, fortunately, in 80–85% of athletes, brain dysfunction resolves within 10 days [6]. Most people with concussion will recover in 7–14 days [13]. American football players who sustained a concussion recovered the performance of the uninjured controls within 5 to 10 days after injury [21]. The cognitive performance deficits in concussed athletes may persist up to 7 [27, 31] and even to 14 days in some cases [31].

However, some athletes may be symptomatic for longer periods, and caution and good follow-up must be implemented. A systematic review of the highest quality literature about concussion was published in 2014 [27], and the answers to the question “What are the most common signs, symptoms, and neurologic and cognitive deficits within three months after a potential concussive event?” revealed:

The recovery from the concussion varies among the athlete-students. The capacity to read without headache or reduced concentration can last for 30 min for some, and others will experience fatigue only after 15 min, but the tolerance for a cognitive activity is expected to increase as the recovery proceeds [22]. One week of cognitive and physical rest was enough to return to baseline on the neurocognitive assessment [22], but the patients involved on more cognitive activity after a concussion took longer time to recover [24]. Naomi J. Brown et al. [30] conducted a prospective cohort study of patients who presented to a Sports Concussion Clinic within 3 weeks of injury to determine the effect of cognitive activity level on duration of post-concussion symptoms. Thirty-five patients were included in the study (mean age of participants was 15 years), 19% reported a loss of consciousness, and 37% reported amnesia at the time of injury. The authors concluded that the increased cognitive activity is associated with longer recovery from concussion.

The neurocognitive test results and the self-reported symptom data had prognostic value in determining time to clinical recovery, and headache symptoms were associated with longer time to clinical recovery [32]. The study by Lau, B. C. et al. [33] investigated cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes. A computer-based neurocognitive test battery (Immediate Post-Concussion Assessment and Cognitive Testing) was applied on the first 48-h post-concussion and then before return to play. Athletes were classified as protracted recovery (>14 days) or short recovery (≤14 days). The authors concluded that there are numerical thresholds for clinicians to predict which concussed athletes will have a protracted recovery [33], and this information can be given to the coach. In the study of Iverson G, [34], “within 72 hours after injury, athletes with complex concussions performed poorly on neuropsychological testing and reported more symptoms than those with simple concussions. Athletes with complex concussions who were slow to recover were 18 times more likely to have three unusually low neuropsychological test scores than those with simple concussions.” This case-control study included high school football players, all completed a computerized neuropsychological screening evaluation within 72 h of injury, and they were clinically followed until they recovered and were cleared to return to play. Another cohort study (level of evidence grade 2) was undertaken to determine which on-field signs and symptoms were predictive of a protracted (≥21 days) versus rapid (≤7 days) recovery after a sports-related concussion [35]. The sample included 107 male high school football athletes who completed computerized neurocognitive testing within an average 2.4 days after injury, and the results showed that dizziness at the time of injury was associated with a 6.34 odds ratio of a protracted recovery from concussion. Surprisingly, the remaining on-field signs and symptoms were not associated with an increased risk of protracted recovery in the current study [35].

The return to academic activities should gradually be increased, the amount of the time related to mental activities is progressive and accordingly to the symptoms, and usually in a period of 10 days, one has resumed the normal academic life [3]. Besides cognitive rest, physical rest is important, and the player is not allowed to train, to play, or to travel for a competition [6]. However, as soon the athlete starts to experience symptoms related to the concussion, he should stop the mental activities and get in cognitive rest once again [3].

Several criteria should be met to determine the endpoint of recovery [7]:

Return to school after a concussion is a significant aspect of concussion management and requires an evidence-based, practical set of guidelines [9] because most children and adolescents look physically normal after a concussion and school officials often fail to recognize the need for academic or environmental adjustments [29]. Concussion recovery is variable [4], and athletes’ concern is related to the return-to-play moment and to the repeated concussions that might cause structural injuries to the brain [19]. However, similar concern must also be directed to the return to school and to the academics activities, because these involve activity on a debilitated brain, and physical activity and cognitive activity are sources of neurometabolic demand on the brain, which will delay the recovery from the concussion [7, 22]. The individual’s sensitivity to physical and cognitive exertion before taking a decision must be considered [7], and the student-athletes should return to their academic and sports activities smoothly and safely [3].

Reduced workload and extended time for tests while recovering from a concussion must be considered to the returning student [5]. Symptom checklists; neuropsychological tests, which are more sensitive for subtle cognitive impairment than clinical exam [5]; and postural stability tests are tools that have been used to monitor recovery [4] and to decide the moment to get back to the nonrestricted full play [3]. However, the athlete must be asymptomatic at “rest,” and no symptoms are elicited by either cognitive activity or physical activity before return-to-sports participation is considered. A graded physical and cognitive activity progression is implemented [22].

There is a discussion about the routine use of baseline neuropsychological testing in order to better interpret the post-concussion scores. A subcommittee of the American Academy of Neurology is in favor of a baseline testing, especially because in some people the neurocognitive testing results might be compromised (previous concussion, for instance) [24]. Also, the National Collegiate Athletic Association (NCAA) from the USA recommends baseline assessments for student-athletes that should include the search for symptoms, balance and cognitive assessments, and neuropsychological tests. Other authors state that there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing, although they recognize the great clinical value of this tool to evaluate the concussion [12]. Neurocognitive assessment is very important in concussion management, even in those cases without baseline assessment, and it is another tool to help to make a decision [3], together with the assessment of the symptoms and other cognitive and balance evaluation, such as those indicated in SCAT3 [12]. Besides, it seems that neurocognitive assessments may be more sensitive to recovery than symptoms alone in concussion management [5, 28], although the information gathered from the analysis of the symptoms must be considered of high value.

The timing for the neurocognitive assessment has been considered, and it has been suggested to be performed 72 h after the concussion [29], because it can provide more information in relation to analysis only of the symptoms, like a protracted recovery [5, 28, 29, 32, 33], although the ideal timing, frequency, and type of neuropsychological testing have not yet been determined [5]. However, most concussions can be managed appropriately without the use of neuropsychological testing, and it should not be used in isolation [5]. At 72-h post-concussion, the analysis might indicate the need for more time to recover and to postpone the return to school and the need for more cognitive (and physical) rest [3]. Any increase on both physical and mental activities will increase the metabolic activity of the brain and it will delay the recovery [9, 22].