What is the appropriate management plan for a patient diagnosed with a concussion?

SOAP Note for Concussion Management

Subjective

• Chief complaint: Concussion
• History of present illness: Patient diagnosed with concussion
• Symptoms may include: headache, dizziness, nausea, visual disturbances, sensitivity to light/noise, cognitive difficulties, sleep disturbances, emotional changes
• Mechanism of injury: [Document specific mechanism]
• Time since injury: [Document]
• Previous concussions: [Document number and dates]

Objective

• Vital signs: Within normal limits
• Neurological examination:
  • Mental status: Alert and oriented x3
  • Cranial nerves: Intact
  • Motor/sensory: Intact
  • Balance assessment: [Document findings]
  • Coordination: [Document findings]
• Cognitive assessment: [Document findings]
• Symptom inventory score: [Document]

Assessment

• Concussion, acute/subacute phase
• Symptom severity: [Mild/Moderate/Severe]

Plan

Patients with concussion should begin a gradual schedule of light aerobic exercise after a brief period of relative rest (24-48 hours), followed by a progressive 5-stage return to activity protocol, with each stage lasting a minimum of 24 hours. 1

Initial Management (First 24-48 Hours)

• Relative rest for 24-48 hours (not complete bed rest) 2, 1
• Avoid activities that exacerbate symptoms
• Acetaminophen only for pain management if needed (avoid NSAIDs, aspirin) 2
• Avoid alcohol and illicit drugs 2, 1
• No same-day return to play/activity 2, 1

Return to Activity Protocol (5-Stage)

1. Stage 1: Symptom-limited activity (24 hours)

   • Gradual reintroduction of daily activities that don't provoke symptoms
   • Light cognitive activities as tolerated

2. Stage 2: Light aerobic exercise (24 hours)

   • Walking, swimming, or stationary cycling at slow pace
   • Keep intensity <70% maximum heart rate
   • No resistance training

3. Stage 3: Sport-specific exercise (24 hours)

   • Running drills, skating drills (sport-specific)
   • No head impact activities

4. Stage 4: Non-contact training drills (24 hours)

   • More complex training drills
   • May start progressive resistance training

5. Stage 5: Full-contact practice (24 hours)

   • Normal training activities with medical clearance

6. Return to full activity/sport/school

Important Instructions

• Progress to next stage only if asymptomatic at current stage
• If symptoms return at any stage, return to previous asymptomatic stage for at least 24 hours 1
• Younger athletes (<18 years) should be managed more conservatively with longer recovery periods 2, 1
• Medical clearance required before full return to play/contact sports 1

Special Considerations

• For persistent symptoms (>10-14 days):
  • Consider referral to concussion specialist 1, 3
  • May need multimodal rehabilitation approach including:
    • Vestibular therapy
    • Vision therapy
    • Cognitive rehabilitation
    • Psychological support

Follow-up

• Schedule follow-up appointment in [X] days
• Return sooner if symptoms worsen
• Contact information provided for questions/concerns

Patient Education

• Explained concussion pathophysiology
• Discussed importance of following gradual return protocol
• Warned about risks of premature return to activities
• Provided written instructions for return to activity protocol

Recent evidence shows that prolonged complete rest can worsen outcomes 2, 4, 5, while appropriate aerobic exercise is beneficial for adolescents with acute concussion 2.