What are the guidelines for diagnosing and managing a concussion?

Concussion Diagnosis and Management Guidelines

Exercise is recommended as an appropriate therapy for adolescents with acute concussion after 24-48 hours of relative rest, while strict bed rest and high-intensity physical activity should be avoided. 1

Diagnosis of Concussion

• Concussion is a clinical diagnosis based on:

  • History of mechanical force to the head
  • Presence of one or more of the following symptoms:
    • Confusion or disorientation
    • Loss of consciousness (≤30 minutes)
    • Post-traumatic amnesia (<24 hours)
    • Transient neurological abnormalities (focal signs, symptoms, seizures)
  • Glasgow Coma Scale score of 13-15 1

• Five concussion subtypes should be assessed during initial evaluation:

  1. Cognitive
  2. Ocular-motor
  3. Headache/migraine
  4. Vestibular
  5. Anxiety/mood 1

• Sleep disturbance should also be evaluated as it commonly accompanies concussion 1

Immediate Management

• Remove from play/activity immediately if concussion is suspected 1, 2
• No return to play on the same day of injury 1
• Initial period of relative rest for 24-48 hours 1, 3
• Avoid activities that worsen symptoms 3
• Ensure adequate hydration and regular sleep schedule 3
• For headaches:
  • First-line: acetaminophen (1000 mg) or ibuprofen (400 mg)
  • Avoid opioids due to risk of dependency and rebound headaches
  • Monitor for analgesic overuse (limit use to ≤15 days/month) 3

Return to Activity Protocol

A 5-stage graded return to activity protocol is recommended:

1. Symptom-limited activity - Daily activities that don't provoke symptoms
2. Light aerobic exercise - Walking, swimming, stationary cycling at slow-moderate pace
3. Sport-specific exercise - Running drills, no head impact activities
4. Non-contact training drills - More complex training drills, progressive resistance training
5. Full-contact practice - Following medical clearance

Key protocol rules:

• Each stage should last a minimum of 24 hours
• Progress only if asymptomatic at current stage
• Return to previous asymptomatic stage for 24 hours if symptoms return 1, 3

Warning Signs Requiring Emergency Care

Instruct patients/families to seek immediate medical attention if:

• Worsening headache
• Repeated vomiting
• Increasing confusion or memory problems
• Focal neurologic deficits
• Abnormal behavior
• Increased sleepiness
• Seizures 3

Management of Persistent Symptoms

• For symptoms persisting >10 days, multidisciplinary management is recommended 1
• For headaches persisting beyond 3-4 weeks, refer to a concussion specialist 3
• Assess headache characteristics to determine if pattern resembles:
  • Migraine
  • Tension-type
  • Cervicogenic headache 3
• Consider vestibular rehabilitation for patients with vestibulo-oculomotor dysfunction 3
• For persistent symptoms beyond 3 months, implement targeted interventions:
  • Graded physical exercise
  • Vestibular rehabilitation
  • Manual therapy
  • Psychological treatment
  • Vision therapy
  • Cognitive rehabilitation 3

Return to Play Requirements

• Medical clearance from a licensed healthcare provider trained in concussion management is required before full return to play 3
• Neuropsychological testing can be used to assist return to play decisions 1
• Return to play should not occur while the patient is taking medications for concussion symptoms 1

Common Pitfalls to Avoid

1. Allowing same-day return to play (significantly increases risk of additional injury)
2. Prescribing strict bed rest (detrimental to recovery)
3. Permitting high-intensity physical activity too soon
4. Overlooking sleep disturbances that may exacerbate symptoms
5. Overuse of analgesics leading to medication-overuse headache
6. Failing to assess for all five concussion subtypes
7. Inadequate follow-up for persistent symptoms
8. Premature return to full activities before completing graded protocol

By following these evidence-based guidelines, clinicians can optimize recovery, minimize complications, and improve outcomes for patients with concussion.