What are the steps for assessing and managing a concussion?

Concussion Assessment: A Structured Approach

Immediately remove the athlete from play when concussion is suspected and perform a systematic evaluation using standardized tools—never allow same-day return to activity regardless of symptom resolution. 1

Immediate Sideline Assessment

Step 1: Initial Stabilization and Monitoring

• Evaluate airway, breathing, circulation, and cervical spine integrity first 2
• Monitor vital signs and level of consciousness every 5 minutes from time of injury until condition clears or athlete is referred 3, 1
• Record exact time of injury and document all serial assessments 3, 1

Step 2: Rapid Screening Battery

Perform the following three-component assessment on the sideline:

Symptom Checklist 3, 1

• Headache, dizziness, nausea, blurred vision, tinnitus, balance problems, memory issues, concentration difficulties

Brief Cognitive Testing 3, 1

• Use Standardized Assessment of Concussion (SAC) to evaluate orientation, immediate memory, concentration, and delayed recall 3

Balance Testing 3, 1

• Administer Balance Error Scoring System (BESS) to assess postural stability 3, 1

Step 3: Neurological Examination

• Assess cranial nerves, motor function, sensory function, reflexes, and coordination 3
• Evaluate for signs of skull fracture, focal neurological deficits, or altered consciousness 1

Comprehensive Post-Injury Assessment

Step 4: Subtype Classification (Within 3 Days)

Evaluate for five concussion subtypes and sleep disturbance, as these guide targeted treatment: 3, 1

• Cognitive subtype: Memory problems, concentration difficulties, mental fogginess
• Vestibular subtype: Dizziness, balance problems (particularly common in pediatric patients) 3
• Ocular subtype: Vision problems, difficulty tracking, convergence insufficiency
• Headache/migraine subtype: Persistent headache with migraine features
• Anxiety/mood subtype: Emotional lability, anxiety, depression 3
• Sleep disturbance: Insomnia, hypersomnia, altered sleep-wake cycle 3, 1

Step 5: Extended Neuropsychological Testing

• Perform computerized neuropsychological testing (e.g., ImPACT) comparing to baseline if available 3, 4
• Conduct more extensive balance testing using computerized systems 3
• Reassess symptom severity using standardized checklists 3

Mandatory Disqualification Criteria

Disqualify from same-day return if ANY of the following are present: 3, 1

• Any loss of consciousness (regardless of duration) 3, 1
• Amnesia lasting longer than 15 minutes 3
• Symptoms persisting at rest or after 20 minutes of exertion 3, 1
• Any concussion symptoms present whatsoever 1

Exertional Testing Protocol

Before considering same-day return (only if symptoms resolved in <20 minutes):

• Sideline jogging followed by sprinting 3
• Sit-ups and push-ups 3
• Sport-specific, non-contact activities 3
• If symptoms recur during any activity, immediate disqualification 3

Physician Referral Criteria

Refer to physician on day of injury if: 3

• Loss of consciousness occurred
• Amnesia lasted >15 minutes
• Symptoms persist beyond initial assessment
• Any red flags present (seizure, focal deficits, severe headache, repeated vomiting)

Follow-Up Monitoring

Days 1-3 Post-Injury

• Monitor for delayed symptom onset every 24-48 hours 3, 1
• Reassess all three domains: symptoms, cognition, balance 3
• Prescribe complete physical and cognitive rest for first 24-48 hours 1
• Implement academic accommodations and cognitive rest for students 1

Persistent Symptoms (>3 Weeks)

• Refer to specialists based on predominant subtype 3, 1:
  • Neurologist for persistent headaches and sleep disturbances 3
  • Vestibular therapist for balance/dizziness issues 1
  • Neuropsychologist for cognitive and mood symptoms 3
• Implement targeted rehabilitation: vestibular therapy, graded exercise, manual therapy 1

Return-to-Activity Protocol

Begin only after completely asymptomatic at rest: 1

1. Complete rest until symptom-free 1
2. Light aerobic exercise (minimum 24 hours) 1
3. Sport-specific training (minimum 24 hours) 1
4. Non-contact training drills (minimum 24 hours) 1
5. Full contact practice (minimum 24 hours) 1
6. Return to game play 1

If symptoms recur at any step, return to previous symptom-free level. 1

Alternative Conservative Approach

If standardized assessment tools unavailable, use 7-day symptom-free waiting period before return-to-play 1

Special Population Considerations

Pediatric Athletes (<18 years)

• Manage with stricter return-to-play guidelines due to longer recovery times 1
• Higher risk of catastrophic second-impact syndrome 1
• Vestibular subtype particularly common—assess and treat early 3

Athletes with Concussion History

• Manage more conservatively due to increased risk of subsequent injuries 1
• Expect slowed recovery and prolonged cognitive dysfunction 1
• Lower threshold for specialist referral 1

Anticoagulated Patients

• Obtain neuroimaging regardless of symptom severity 5
• Consider 24-hour observation with repeat CT at 20-24 hours post-injury 5

Team-Based Decision Making

Use multidisciplinary approach involving: 3, 1

• Athletic trainer or primary evaluator
• Team physician or primary care provider
• Neurologist (for persistent symptoms) 3
• Neuropsychologist (for test interpretation and cognitive symptoms) 3
• The athlete themselves 3

Integrate all data before return-to-play decision: physical examination, imaging studies, objective testing (cognitive and balance), and exertional testing results 3

Critical Pitfalls to Avoid

• Never assume absence of loss of consciousness rules out concussion 1
• Never allow same-day return even if symptoms resolve quickly—monitor closely at 24 and 48 hours 3, 1
• Never rely on single assessment tool—use combination of symptom, cognitive, and balance measures 3
• Never skip exertional testing before return-to-play clearance 3
• Never dismiss head trauma without proper screening, even if mechanism seems minor 1