What is the proper assessment and management of a concussion injury?

Concussion Assessment and Management

Immediately remove any athlete from play when concussion is suspected and do not allow return to activity on the same day of injury, regardless of symptom resolution. 1

Immediate Sideline Assessment

Monitor the injured athlete every 5 minutes from the time of injury until their condition completely clears or they are referred for further care. 1

Key Assessment Components

Perform a structured evaluation using:

• Standardized symptom checklist documenting severity of headache, dizziness, nausea, balance problems, feeling "dinged" or stunned, visual disturbances, and cognitive symptoms 1, 2
• Brief cognitive testing including the Standardized Assessment of Concussion (SAC) or Maddock's questions assessing attention and memory—standard orientation questions (time, place, person) are unreliable in sports settings 1
• Balance Error Scoring System (BESS) to detect postural instability, though balance testing is specific but not sensitive for concussion 1, 2, 3
• Neurological examination checking for loss of consciousness, altered mental status, gait disturbances, slurred speech, and inappropriate behavior 1

Critical pitfall: Loss of consciousness is not required for concussion diagnosis—most concussions occur without LOC. 1, 3

Immediate Disqualification Criteria

Disqualify from same-day return if:

• Any loss of consciousness or amnesia occurred 1
• Symptoms persist at rest or after exertion for at least 20 minutes 1
• Any concussion symptoms are present, even if mild 1, 2

Athletes who become asymptomatic quickly (<20 minutes) and return the same day require repeated reevaluation on the sideline, after the game, and at 24 and 48 hours post-injury to identify delayed symptom onset. 1

Physician Referral Indications

Refer to a physician on the day of injury if: 1

• Loss of consciousness occurred
• Amnesia lasted longer than 15 minutes
• Symptoms are worsening or not improving
• Any red flags suggesting intracranial bleeding (severe headache, vomiting, seizures, focal neurological deficits)

Initial Management (First 24-48 Hours)

Prescribe complete physical and cognitive rest for the first 24-48 hours post-injury. 2 This includes:

• No sports or physical exertion 2
• Cognitive rest: limit screen time, reading, schoolwork, and mentally demanding activities 2, 3
• Avoid all medications except acetaminophen as recommended by a physician 2

Important caveat: While initial rest is recommended, prolonged activity restriction beyond a few days may worsen outcomes and contribute to persistent symptoms through physical deconditioning and psychological effects. 4

Subtype Assessment (Within First 3 Days)

Evaluate for five concussion subtypes to guide targeted treatment: 2

• Cognitive dysfunction
• Vestibular impairment
• Ocular motor dysfunction
• Headache/migraine pattern
• Anxiety/mood disturbance
• Associated sleep disturbance

Return-to-Activity Protocol

Begin only after the athlete is completely asymptomatic at rest. 1, 2 Each step requires a minimum of 24 hours; if symptoms recur at any step, return to the previous asymptomatic level. 1, 2

Stepwise Progression:

1. Complete rest until asymptomatic 1, 2
2. Light aerobic exercise (walking, stationary cycling) 1, 2
3. Sport-specific training without contact (skating, running drills) 1, 2
4. Non-contact training drills 1, 2
5. Full contact practice after medical clearance 1, 2
6. Return to game play 1, 2

If standardized assessment tools (SAC, BESS, neuropsychological testing, symptom checklist) are not used, a 7-day symptom-free waiting period before return-to-play is recommended. 1

Academic Accommodations

Students require cognitive rest and academic accommodations including: 2, 3

• Reduced workload
• Extended time for tests
• Gradual return to full academic schedule as tolerated

Special Populations Requiring Conservative Management

Athletes with Concussion History

Manage more conservatively as they have increased risk of: 1

• Subsequent injuries
• Slowed recovery
• Prolonged cognitive dysfunction and postural instability

Athletes with three or more prior concussions and slowed recovery may require temporary or permanent disqualification from contact sports. 1

Young Athletes (<18 Years)

Manage pediatric athletes with stricter return-to-play guidelines because: 1

• Recovery takes longer than in older athletes 1
• Risk of catastrophic second-impact syndrome (almost exclusively occurs in young athletes) 1
• Require more frequent baseline measure updates due to rapid maturation 1

Persistent Symptoms (Beyond 3 Weeks)

For symptoms persisting beyond 3 weeks, refer to specialists and implement targeted interventions based on subtype: 2

• Vestibular rehabilitation for vestibular symptoms
• Graded physical exercise programs
• Manual therapy for cervicogenic components
• Specialist consultation (neurology, neuropsychology, sports medicine)

Team Approach to Decision-Making

Use a multidisciplinary team including athletic trainers, physicians, the athlete, neuropsychologists when available, and any specialist consultants to make return-to-play decisions. 1, 2 Assessment should integrate physical examination, imaging studies when indicated, objective testing, and exertional testing results. 1

Neuropsychological testing (computerized or comprehensive paper-and-pencil) provides objective cognitive assessment but should be used only as part of comprehensive management, not in isolation. 3 Baseline testing maximizes clinical utility. 1