What are the implications and management of a standardized assessment of concussion score of 25, indicating a mild concussion?

Management of Mild Concussion with a Standardized Assessment of Concussion Score of 25

A Standardized Assessment of Concussion (SAC) score of 25 indicates a mild concussion that requires a structured approach to management with initial rest followed by gradual return to activity, while avoiding both prolonged strict rest and high-intensity physical activity.

Initial Management (First 24-48 Hours)

• Implement brief physical and cognitive rest for the first 24-48 hours after concussion to allow for initial recovery during the acute neurometabolic cascade 1, 2
• Avoid strict prolonged rest (exceeding 3 days) as this may be detrimental to recovery 1, 3
• Monitor for warning signs requiring immediate medical attention including repeated vomiting, worsening headache, confusion, focal neurologic deficits, abnormal behavior, increased sleepiness, loss of consciousness, or seizures 2
• NSAIDs and aspirin should be avoided immediately after a suspected head injury due to theoretical risk of intracranial bleeding 4
• Acetaminophen may be used for symptom management, but there is no evidence demonstrating efficacy in alleviating symptoms or shortening the course of concussion 4

Cognitive Rest and School Considerations

• Implement "cognitive rest" to prevent exacerbation of symptoms and allow for continued recovery 4
• This may include:
  • Temporary leave of absence from school or shortened school day 4
  • Reduction of workloads and allowance of more time for assignments/tests 4, 2
  • Postponement of standardized testing 4
• Avoid activities requiring concentration and attention that may exacerbate symptoms:
  • Video games, computer use, television viewing 4
  • Exposure to loud music (if phonophobia is present) 4
  • Consider sunglasses for significant photophobia 4
• After reintegration into school:
  • Allow adequate time to make up assignments 4
  • Reduce overall volume of make-up work 4
  • Communicate with school personnel to ensure understanding of accommodations 4, 2

Gradual Return to Physical Activity

• After the initial 24-48 hour rest period, begin gradual return to activity rather than prolonged complete rest 1, 2
• Implement a progressive schedule with close monitoring of symptom expression (number and severity) 1
• Each step in return-to-activity protocol should take a minimum of 24 hours 2:
  1. Light aerobic exercise (walking, swimming, stationary cycling) at low to moderate intensity 1, 2
  2. Sport-specific training (running drills, skating drills) 2
  3. Non-contact training drills (more complex training, passing drills) 2
  4. Full contact practice (following medical clearance) 2
  5. Return to normal activity/competition 2
• Exercise should be performed below symptom exacerbation threshold 1, 2
• Supervised, non-contact aerobic exercise is particularly beneficial for adolescents with acute concussion 1

Return to Full Activity Criteria

• Allow return to full activity when 1, 4:
  • The athlete has returned to premorbid performance
  • Remains symptom-free at rest
  • Shows no symptom recurrence with increasing physical exertion
• Athletes who are symptomatic at rest and after exertion for at least 20 minutes should be disqualified from returning to participation on the day of the injury 4
• Athletes who experienced loss of consciousness or amnesia should be disqualified from further participation on the day of the injury 4

Management of Persistent Symptoms (Beyond 2-3 Weeks)

• If symptoms persist beyond 3 weeks, referral to a specialist in traumatic brain injury is recommended 2
• For persistent symptoms, implement:
  • Graded physical exercise performed at least once weekly for a minimum of 4 weeks 2
  • Vestibular rehabilitation for persistent vestibular dysfunction 2
  • Manual therapy for the neck and spine when neck pain is present 2

Important Considerations and Pitfalls

• Avoid high-intensity physical activity during recovery as this can be detrimental 1, 4
• Be more conservative in treating athletes with a history of concussion, as they have increased risk of subsequent injuries and slowed recovery 4
• For younger athletes (<18 years), management should be more conservative due to potential catastrophic effects on the maturing brain 4
• Continued medication use to control concussion symptoms indicates incomplete recovery; medications must be stopped and the athlete must remain symptom-free off medication before considering return to play 4
• A team approach should be used in making return-to-play decisions, involving input from athletic trainers, physicians, the athlete, and any referral sources 4

The SAC score of 25 is a useful data point, but should be considered alongside other clinical findings, as the SAC has limitations in fully capturing the multidimensional nature of concussion recovery 5, 6.