What is the recommended approach for post-concussion assessment and management?

Post-Concussion Assessment and Management

A comprehensive post-concussion assessment should include a standardized symptom checklist, neurological examination, balance assessment, and cognitive function evaluation, with neuroimaging reserved only for cases with suspected structural brain abnormalities. 1

Initial Assessment Components

Symptom Evaluation

• Use a standardized symptom checklist to assess:
  • Physical symptoms: headache, dizziness, nausea, balance problems, visual disturbances, sensitivity to light/noise 1
  • Cognitive symptoms: feeling "foggy," difficulty concentrating, memory problems 2
  • Emotional symptoms: irritability, sadness, nervousness 2
  • Sleep disturbances: trouble falling asleep, sleeping more than usual 2

Neurological Examination

• Mental status assessment
• Cranial nerve testing
• Motor and sensory examination
• Deep tendon reflexes
• Coordination testing 1

Balance Assessment

• Balance Error Scoring System (BESS) in 3 positions on firm and foam surfaces
• Romberg test
• Tandem gait assessment 1

Cognitive Function Evaluation

• Standardized Assessment of Concussion (SAC) - 95% sensitive and 76% specific when any decrease from baseline is observed 1
• Maddock's questions (more reliable than standard orientation questions) 1, 2

Neuroimaging Considerations

• Conventional neuroimaging (CT/MRI) is typically normal in concussion and contributes little to evaluation 2, 1
• Reserve CT scans for patients with:
  • Glasgow Coma Scale score less than 15
  • Suspected open or depressed skull fracture
  • Worsening headache or neurological status
  • Focal neurological deficit
  • Seizure activity
  • Persistent clinical or cognitive symptoms 2, 1

Acute Management

When a player shows ANY symptoms or signs of concussion:

1. Remove from play/activity immediately - no same-day return to play 2, 1
2. Do not leave the patient alone; monitor regularly for deterioration 2
3. Conduct medical evaluation 2
4. Provide clear discharge instructions about warning signs, expected symptoms, and activity restrictions 1

Return to Play/Activity Protocol

Follow this stepwise process:

1. No activity, complete rest until asymptomatic
2. Light aerobic exercise (walking, stationary cycling)
3. Sport-specific training (e.g., skating in hockey, running in soccer)
4. Non-contact training drills
5. Full contact training after medical clearance
6. Game play/full activity 2

Important: Progress to next level only if asymptomatic at current level. If any symptoms occur, drop back to previous asymptomatic level and try again after 24 hours 2.

Common Pitfalls to Avoid

• Relying on loss of consciousness: Occurs in less than 10% of concussions and is not a reliable severity indicator 1
• Overusing neuroimaging: Routine CT/MRI contributes little unless structural injury is suspected 1
• Using standard orientation questions: Memory assessment is more sensitive than time/place/person orientation 1
• Premature return to activity: Can lead to prolonged recovery or second-impact syndrome 3
• Inadequate follow-up planning: Patients need clear guidelines on when to seek further medical attention 1

Special Considerations

• Students may require cognitive rest and academic accommodations (reduced workload, extended time for tests) 3
• If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, referral to a multidisciplinary concussion center is recommended 4
• Neuropsychological testing may be helpful for patients with persistent symptoms or complicated recovery courses 3

By following this structured approach to post-concussion assessment and management, clinicians can optimize recovery outcomes and minimize the risk of complications.