What are the steps for diagnosing and managing a concussion?

Concussion Diagnosis and Management

Concussion is a clinical diagnosis made by identifying characteristic symptoms and signs following head trauma, with immediate removal from activity and a structured stepwise return-to-play protocol after 24-48 hours of initial rest. 1, 2

Diagnostic Criteria

The diagnosis of concussion is entirely clinical—no imaging or biomarker definitively confirms it. 2 Look for these specific indicators:

Most Reliable Immediate Signs (within 48 hours)

• Disorientation or confusion immediately following the injury is the single most reliable indicator 2
• Impaired balance assessed using standardized tools like the Balance Error Scoring System (BESS) within the first day 2
• Slower reaction time measured within 2 days of injury 2
• Impaired verbal learning and memory within 2 days provides objective cognitive dysfunction evidence 2

Critical Pitfall to Avoid

• Loss of consciousness is NOT required for diagnosis and occurs in only a minority of cases—do not wait for LOC to diagnose concussion 2

Red Flags Requiring Immediate CT Imaging

• Repeated vomiting 1
• Worsening or severe headache 1, 3
• Focal neurologic deficits 1
• Altered mental status or deteriorating consciousness 1, 3
• Seizures 1, 3
• Visual changes 3

Initial Assessment Tools

Use these structured assessments on the sideline or in clinic:

• Graded symptom checklists to objectively track symptom severity over time 4
• Standardized Assessment of Concussion (SAC) for cognitive evaluation including orientation, memory, and concentration 4, 5
• Balance Error Scoring System (BESS) for objective balance testing 2, 5
• Neurological examination focusing on cranial nerves, coordination, and gait 6

Concussion Subtype Classification

Identify the predominant subtype(s) to guide targeted treatment—multiple subtypes commonly coexist: 6, 2

• Cognitive subtype: Difficulty concentrating, memory problems, slowed processing 2
• Vestibular subtype: Dizziness, balance problems, motion sensitivity 6
• Ocular-motor subtype: Vision problems, difficulty tracking, convergence insufficiency 6
• Headache/migraine subtype: Persistent headache with migraine features 6
• Anxiety/mood subtype: Emotional lability, anxiety, depression 6
• Sleep disturbance: Insomnia or hypersomnia patterns 6, 2
• Cervical strain: Neck pain, limited range of motion, often coexists with concussion 6, 2

Acute Management Protocol

Immediate Actions

• Remove from play immediately—"When in doubt, sit them out!" No same-day return to play under any circumstances 1, 3, 4
• Monitor for deterioration in the first 24-48 hours, particularly for red flag symptoms 4

Initial Rest Period (First 24-48 Hours)

• Implement moderate physical and cognitive rest for 24-48 hours to allow recovery during the acute neurometabolic cascade 1, 3
• Cognitive rest includes: Limiting activities requiring concentration, reducing screen time (video games, computer, television), avoiding loud music, and minimizing reading 1, 3
• Avoid strict prolonged rest exceeding 3 days—this worsens outcomes and is detrimental to recovery 1, 7

Medication Management

• Use acetaminophen only for symptom management 1, 3
• Avoid NSAIDs and aspirin due to theoretical bleeding risk in the acute phase 1
• Never allow return to play while taking any medications for concussion symptoms—this indicates incomplete recovery 6, 3, 4

Stepwise Return-to-Play Protocol

After the initial 24-48 hour rest period, begin this graduated protocol: 1, 3

The Six-Step Protocol

1. Light aerobic exercise (walking, stationary cycling) at <70% maximum heart rate, no resistance training 1
2. Sport-specific exercise (skating drills, running drills) with no head impact activities 1
3. Non-contact training drills with progressive resistance training 1
4. Full-contact practice after medical clearance 1
5. Return to competition 1

Progression Rules

• Each step requires a minimum of 24 hours before advancing 6, 1, 3
• If any symptoms recur at any step, return to the previous asymptomatic level and rest 24 hours before attempting progression again 6, 1, 3
• Supervised, sub-symptom threshold aerobic exercise is particularly beneficial for adolescents with acute concussion 1

School Accommodations

Students require temporary academic modifications during recovery: 3, 4

• Shortened school days 3
• Reduced workload 3
• Extended time for assignments and tests 3
• Postponement of standardized testing 3
• Excused absences as needed 3

Management of Persistent Symptoms (>10 Days)

Symptoms persisting beyond 10 days require multidisciplinary management: 6, 1, 3

Subtype-Specific Interventions

• Vestibular symptoms: Vestibular rehabilitation therapy 1
• Cervical symptoms: Manual therapy and cervical physical therapy 1
• Ocular-motor symptoms: Vision therapy 1
• Mood/anxiety symptoms: Cognitive behavioral therapy 1
• Persistent symptoms: Graded sub-threshold aerobic exercise 1

When to Refer

• Refer to traumatic brain injury specialist if symptoms persist beyond 3 weeks 1
• Consider formal neuropsychological assessment for persistent cognitive symptoms 3, 4

Role of Neuropsychological Testing

Neuropsychological testing is helpful but not required for most concussions: 4, 5

• Use as part of comprehensive management, never in isolation 4
• Computerized testing must be interpreted by trained professionals familiar with test limitations, reliable change indices, and false-positive/negative rates 4
• Paper-and-pencil tests are more comprehensive and can assess for conditions masquerading as concussion 4
• Most useful for complicated cases with persistent symptoms or multiple concussions 4

Special Populations

Pediatric and Adolescent Athletes

• Manage more conservatively with stricter return-to-play guidelines—younger athletes have longer recovery times and developing brains are more vulnerable 6, 3
• Youth athletes are at higher risk for catastrophic injury with premature return to play 6, 4

Athletes with Pre-existing Conditions

• Mood disorders, learning disorders, ADHD, and migraine headaches complicate diagnosis and management—these require individualized approaches 4

Critical Pitfalls to Avoid

• Never allow same-day return to play after diagnosed concussion 6, 3, 4
• Do not rely solely on patient-reported symptoms—athletes commonly underreport to return to play faster 6, 3
• Avoid prolonged strict rest beyond 3 days—this can worsen outcomes through deconditioning and activity restriction cascade 1, 7
• Do not return athletes taking concussion medications—this masks incomplete recovery 6, 3, 4
• Never skip steps in the return-to-play protocol even if the athlete feels fine 1

Long-Term Considerations

• History of concussion increases risk of subsequent concussions 4, 5
• Multiple concussions, particularly within 10 days, significantly increase risk of prolonged recovery 4, 5
• Repeated concussions may contribute to long-term neurological sequelae, though large-scale studies are needed to define causation 4
• Counsel patients and families about potential long-term consequences of concussion and recurrent concussions 4