What is the appropriate treatment and management for a suspected concussion?

Management of Suspected Concussion

Athletes with a suspected concussion should be immediately removed from play, evaluated by a healthcare professional, and should never return to play on the same day of injury, even if symptoms resolve quickly. 1

Initial Assessment and Diagnosis

• Concussion is a clinical diagnosis based on a traumatically induced transient disturbance of brain function, typically presenting with rapid onset of short-lived neurological impairment 1, 2
• Sideline evaluation should include:
  • Standardized symptom assessment using a checklist 1
  • Cognitive assessment (orientation, memory, concentration) using tools like Standardized Assessment of Concussion (SAC) 1
  • Balance testing (Balance Error Scoring System) 1
  • Neurological examination 1
• Standard neuroimaging (CT, MRI) is typically normal in concussion and should be reserved for cases where intracranial bleeding is suspected 1, 2

Key Signs and Symptoms to Evaluate

• Physical signs: Loss of consciousness, poor coordination, balance problems, gait unsteadiness 1
• Typical symptoms: Headache, dizziness, nausea, feeling "dazed," visual disturbances, ringing in ears 1
• Cognitive symptoms: Confusion, memory problems, difficulty concentrating, slow responses 1
• Emotional/behavioral changes: Unusual emotions, personality changes, irritability 1, 3

Treatment Protocol

Immediate Management

• Remove from play immediately when concussion is suspected 1
• Monitor at 5-minute intervals until condition stabilizes or referral is made 1
• Refer to physician on the day of injury if loss of consciousness occurred, amnesia lasted >15 minutes, or symptoms are severe 1

Rest Recommendations

• Both physical AND cognitive rest until symptoms resolve both at rest and with exertion 1
• Avoid strict/complete rest as this may have detrimental effects 1
• Cognitive rest may include:
  • Temporary leave from school or shortened school days
  • Reduced academic workload
  • Extended time for assignments and tests
  • Avoidance of reading and screen time that worsens symptoms 1, 2

Medication Considerations

• There is no evidence supporting the efficacy of medications in treating concussion 1
• NSAIDs and aspirin should be avoided immediately after injury due to theoretical risk of intracranial bleeding 1
• Medications for symptom management (headache, sleep disturbances) may be considered for prolonged symptoms, but athletes must be symptom-free without medication before return to play 1

Return to Activity Protocol

• No same-day return to play for any athlete diagnosed with concussion 1, 2
• Athletes should not return to play while symptomatic at rest or with exertion 1, 2
• Implement a gradual, step-wise return to play progression:
  1. Complete rest until asymptomatic
  2. Light aerobic exercise (walking, swimming, stationary cycling)
  3. Sport-specific exercise without head impact
  4. Non-contact training drills
  5. Full-contact practice after medical clearance
  6. Return to competition 1, 2
• If symptoms recur at any step, return to previous asymptomatic step 2
• Medical clearance must be obtained before return to play 1, 2

Special Considerations

• Recovery is typically longer in children and adolescents than in college/professional athletes; more conservative approach is warranted 1, 4
• Athletes with amnesia may have more severe deficits and slower recovery trajectory 4
• Most concussions resolve within 7-10 days, but some athletes may take weeks to months to recover 1, 4
• Athletes with multiple prior concussions may demonstrate poorer balance recovery 4
• Consider neuropsychological testing as an objective measure of cognitive function and recovery, though it should not be used in isolation 1, 2

When to Refer for Specialist Care

• Loss of consciousness >30 seconds (may indicate more significant injury) 1
• Symptoms worsening over time rather than improving 1
• Persistent symptoms beyond 10-14 days 1, 2
• History of multiple concussions 1
• Pre-existing conditions (learning disabilities, ADHD, migraines) that complicate assessment 2
• Consider multidisciplinary approach including neurologists for persistent symptoms and neuropsychologists for cognitive assessment 1

Prevention Strategies

• Education of athletes, parents, coaches, and healthcare providers about concussion recognition and management 2
• Proper enforcement of rules and fair play in sports 2
• Consideration of retirement from contact sports for athletes with history of multiple concussions or prolonged symptoms 1