What is the assessment and treatment approach for a patient with a concussion 1 month ago?

Assessment and Management of Concussion at 1 Month Post-Injury

At 1 month post-concussion, you should actively assess for persistent post-concussive symptoms using a standardized symptom checklist and immediately initiate sub-symptom threshold aerobic exercise combined with domain-specific rehabilitation rather than continuing rest, as most patients recover within 3 months but 15-20% will develop post-concussion syndrome requiring active intervention. 1, 2, 3

Systematic Assessment Approach

Symptom Evaluation

• Use a standardized symptom checklist (such as the Rivermead Post-Concussion Symptoms Questionnaire) to systematically evaluate all three domains: physical (headache, dizziness, fatigue), cognitive (memory problems, concentration difficulties, forgetfulness), and emotional symptoms (irritability, anxiety, depression). 4, 5
• The most prevalent persistent symptoms at 1 month are fatigue (17.2%) and forgetfulness (14.6%). 2
• Document symptom severity on a 0-4 scale to track recovery trajectory over time. 4

Risk Stratification for Prolonged Recovery

Identify high-risk features that predict persistent symptoms beyond 3 months: 4, 2

• Female gender (strongest predictor)
• Previous psychiatric history (depression, anxiety, PTSD)
• Age >40 years 6
• High initial symptom burden at time of injury
• History of prior concussions
• GCS score <15 at initial presentation 4

Domain-Specific Objective Testing

Beyond symptom checklists, perform targeted assessments: 4, 2

• Cognitive function: Test immediate and delayed recall of 5 words, concentration, and memory 4
• Vestibular function: Assess for dizziness, balance disturbance, and visual motion sensitivity 2, 3
• Cervical spine: Evaluate for neck pain and cervicogenic headache 2, 3
• Visual function: Screen for convergence insufficiency, accommodation problems, and eye movement abnormalities 2, 3
• Postural stability: Use balance testing to identify ongoing deficits 4

Active Treatment Protocol

Cornerstone: Sub-Symptom Threshold Aerobic Exercise

Immediately initiate graded aerobic exercise at 60-70% maximum heart rate for 15-20 minutes daily, gradually increasing duration and intensity as tolerated. 1, 2, 3 This is the single most important intervention with demonstrated positive effects on overall symptom burden, physical functioning, emotional symptoms, and quality of life. 2, 3

• Exercise should be performed below the threshold that exacerbates symptoms—if symptoms worsen significantly during activity, reduce intensity but do not stop completely. 2
• Do not prescribe complete rest at this stage, as prolonged rest beyond 48-72 hours may actually delay recovery and worsen outcomes. 1, 2, 3

Domain-Specific Interventions

For vestibular symptoms (dizziness, imbalance):

• Initiate vestibular rehabilitation including habituation exercises, adaptation exercises, and balance training at least once weekly for minimum 4 weeks. 2, 3
• This demonstrates positive effects on physical functioning and readiness to return to activities. 2, 3

For persistent headache:

• Continue acetaminophen 650-1000mg every 6 hours as needed (maximum 4000mg/24 hours) as first-line. 1
• Add NSAIDs if acetaminophen alone is insufficient. 1
• Never use opioids or butalbital-containing medications, as they are contraindicated and worsen outcomes. 1

For neck pain with headache:

• Implement spinal manual therapy (mobilization/manipulation of cervical spine), which shows positive effects on pain reduction and return to activities. 2, 3

For visual symptoms:

• Refer for oculomotor vision treatment including vergence training, accommodative training, and eye movement exercises. 2, 3

For cognitive symptoms:

• Gradually increase duration and intensity of cognitive activities as tolerated, with goal of increasing participation without significantly exacerbating symptoms. 2
• Implement partial cognitive rest: reduce screen time to 30-minute intervals with breaks, limit reading duration, consider shortened work/school days with reduced workload. 1

For emotional symptoms (anxiety, depression, irritability):

• Offer individual or group psychological therapy at least 1 hour weekly for minimum 4 weeks, which shows positive effects on overall symptom burden, emotional symptoms, and quality of life. 2, 3

Comprehensive Information Provision

Provide systematic, individualized information about symptom management, expected recovery course, and self-care strategies delivered over an extended period—this has strong evidence (Grade A) for reducing overall symptom burden and preventing memory problems. 2 Tailor information to the patient's specific needs rather than generic handouts. 2

Specialist Referral Criteria

Refer to a concussion specialist or sports medicine physician if: 1

• Symptoms persist beyond 3 weeks from initial injury
• Symptoms significantly worsen despite conservative management
• Patient plans to return to contact sports
• Multiple domains are affected requiring interdisciplinary coordinated rehabilitation 3

Critical Red Flags Requiring Immediate ED Evaluation

Instruct the patient to return immediately for: 1

• Repeated vomiting
• Worsening or severe headache
• Increasing confusion or abnormal behavior
• Focal neurologic deficits
• Increased sleepiness or difficulty arousing
• Seizures

Prognosis and Timeline

• Most patients (80-85%) recover completely within 3 months of injury. 1, 3
• Persistent symptoms beyond 3 months occur in 15-20% and constitute post-concussion syndrome. 1, 3
• Problems may persist for at least 6 months and require not only continued medical care but also social assistance with driving support, employment issues, and financial assistance during recovery. 4, 2

Common Pitfalls to Avoid

• Do not wait for spontaneous recovery—active management at 2 weeks to 1 month can prevent progression to persistent post-concussion syndrome. 2
• Do not prescribe strict bed rest or complete activity restriction at this stage, as this may prolong recovery. 1, 2, 3
• Do not use medications to mask symptoms to allow premature return to activities—any medication needed to control symptoms indicates incomplete recovery. 1
• Do not rely solely on patient self-report without objective assessment—systematically evaluate specific domains (vestibular, visual, cervical, cognitive). 2
• Do not discharge without written instructions at a 6th-7th grade reading level given to both patient and caregiver, including information about post-concussion syndrome possibility. 4, 1

Monitoring and Follow-up

• Continue collaborative monitoring with patient and family to determine what modifications are needed to maintain activities without significantly exacerbating symptoms. 2
• Serial reassessments should document presence or absence of symptoms across all three domains (physical, cognitive, emotional). 4
• If symptoms are not improving or worsening at 6 weeks, strongly consider referral for interdisciplinary coordinated rehabilitation involving at least two different healthcare disciplines. 3