Concussion Assessment and Management Protocol
A comprehensive concussion assessment should include evaluation for five concussion subtypes (cognitive, vestibular, ocular, headache/migraine, anxiety/mood) and associated sleep disturbance, as these are common within the first 3 days following injury. 1
Initial Assessment
- Immediately remove the athlete from play when concussion is suspected 1
- Record time of injury and document serial assessments, noting presence or absence of signs and symptoms 1
- Monitor vital signs and level of consciousness every 5 minutes until the athlete's condition improves 1
- Assess for obvious signs (fluctuating consciousness, balance problems, memory issues) and self-reported symptoms (headache, tinnitus, nausea) 1
- Evaluate the cervical spine and cranial nerves to identify any cervical spine or vascular intracerebral injuries 1
Sideline Assessment Tools
- Use a combination of brief screening tools appropriate for sideline evaluation: 1, 2
- Standardized Assessment of Concussion (SAC)
- Balance Error Scoring System (BESS)
- Symptom checklist
- Document all findings using a standardized symptom checklist to track severity and progression 1
- No athlete with diagnosed concussion should return to play on the same day 3
Immediate Referral Criteria
- Refer to a physician on the day of injury if the athlete: 1
- Lost consciousness
- Experienced amnesia lasting longer than 15 minutes
- Shows deteriorating mental status
- Has focal neurological deficits
- Experiences repeated vomiting or worsening headache 4
Comprehensive Evaluation
- For high-risk sports, consider baseline cognitive and postural stability testing before the season 1
- Assess for the five concussion subtypes: 1
- Cognitive (memory, concentration problems)
- Vestibular (balance, dizziness issues)
- Ocular (visual disturbances)
- Headache/migraine (most common in adults)
- Anxiety/mood (present in up to a third of concussed individuals)
- Evaluate for sleep disturbances, which commonly accompany concussion 1, 4
Management Protocol
- Prescribe complete physical and cognitive rest for the first 24-48 hours 4
- Avoid medications except acetaminophen as recommended by a physician 4
- Monitor for delayed signs and symptoms for several days after injury 1
- Implement cognitive rest and academic accommodations for students: 4, 3
- Temporary leave of absence if needed
- Shortened school days
- Reduced workload
- Extended time for assignments and tests
Return to Activity Protocol
- Once symptom-free, reassess to establish that cognition and postural stability have returned to normal 1
- Follow a structured return to activity protocol with each step taking minimum 24 hours: 4
- No activity (complete rest)
- Light aerobic exercise (walking, swimming, stationary cycling)
- Sport-specific training (non-impact activities)
- Non-contact training drills
- Full contact practice (after medical clearance)
- Return to normal activity/play
- If symptoms recur during any step, return to the previous symptom-free step 4, 3
Management of Persistent Symptoms
- For symptoms persisting beyond 3 weeks, consider referral to specialists 4
- Implement targeted approaches based on subtype: 1
- Vestibular rehabilitation for vestibular dysfunction
- Graded physical exercise for persistent symptoms
- Manual therapy for neck and spine when neck pain is present
Common Pitfalls to Avoid
- Using the term "ding" to describe concussion (diminishes injury seriousness) 1
- Returning to activity before symptoms have resolved 4
- Relying on a single test to determine recovery (use multiple assessment tools) 1
- Inadequate rest in initial 24-48 hours or strict rest beyond 48 hours 4
- Failing to monitor for delayed symptoms 1
Team Approach
- Use a team approach for return-to-play decisions, involving athletic trainers, physicians, the athlete, and any referral sources 1
- Secure specialist referrals (neurologists, neuropsychologists) for persistent symptoms 1
- Ensure all evaluators are appropriately trained in standardized test administration and scoring 1