Concussion Evaluation and Management Post Head Injury
Immediately remove the patient from activity and never allow same-day return to play, even if symptoms resolve—this is the single most critical safety measure to prevent catastrophic outcomes. 1, 2
Immediate Assessment and Red Flags
Evaluate immediately for high-risk features requiring emergency CT imaging and potential neurosurgical intervention:
- Loss of consciousness or altered mental status 2
- Severe or progressively worsening headache 1, 2
- Repeated vomiting 1, 2
- Seizure activity 2
- Focal neurological deficits 2
- Signs of skull fracture 2
- Glasgow Coma Scale score <15 at any point 2
Critical pitfall: Missing these red flags can result in undiagnosed intracranial hemorrhage with devastating consequences. When any of these are present, obtain non-contrast head CT immediately. 2
Initial Management: The 24-48 Hour Window
Implement moderate physical and cognitive rest for the first 24-48 hours only—not longer. 1, 3, 2 This initial rest period allows the neurometabolic cascade to stabilize without the detrimental effects of prolonged inactivity.
Physical Rest (First 24-48 Hours)
- No sports, exercise, or strenuous physical activity 2
- Avoid activities that significantly increase heart rate 2
- No contact or collision activities 2
Cognitive Rest (First 24-48 Hours)
- Limit screen time significantly 2
- Reduce academic workload 2
- Avoid activities requiring intense concentration 2
Critical pitfall: Strict rest exceeding 3 days is detrimental and can worsen outcomes, prolong recovery, and contribute to physical deconditioning and depression. 1, 3, 2, 4 The evidence clearly shows that prolonged activity restriction itself becomes part of the problem.
Gradual Return to Activity Protocol (After 24-48 Hours)
Begin supervised, sub-threshold aerobic exercise after the initial 24-48 hour rest period. 1, 3 This is particularly well-supported in adolescents, where exercise has strong evidence as an appropriate therapy for acute concussion. 5, 3
Stepwise Progression (Minimum 24 Hours Per Step)
Each step requires complete symptom resolution before advancing:
Light aerobic exercise (walking, swimming, stationary cycling—no resistance training) 5, 1, 2
Sport-specific exercise (skating drills in hockey, running drills in soccer—no head impact) 5, 1, 2
Non-contact training drills (passing drills, more complex training—may add resistance training) 1, 2
Full-contact practice (following medical clearance only) 1, 2
If symptoms recur at any step: Drop back to the previous asymptomatic level, rest for 24 hours, then attempt to progress again. 5, 1, 2
Critical pitfall: Advancing too quickly through the protocol increases risk of prolonged symptoms and repeat injury. Each 24-hour minimum must be respected. 5
Return to School/Cognitive Activities
Gradually increase academic activities in parallel with physical recovery. 1, 3, 2 Most patients can begin this process after the initial 24-48 hour rest period.
Academic Accommodations (As Needed)
- Shortened school days 1, 2
- Extended time for assignments and tests 1, 2
- Reduced workload 1, 2
- Scheduled breaks during the day 2
These accommodations should be temporary and gradually removed as symptoms improve. 1
Absolute Contraindications to Return to Play
Do not clear for return to play if:
- Patient is taking any medications for concussion symptoms 5
- Any symptoms persist at rest 5, 1
- Symptoms recur with exertion 1, 2
- Patient has not returned to premorbid performance level 1, 2
Management of Persistent Symptoms (>10 Days)
Implement multidisciplinary management for symptoms persisting beyond 10 days. 5, 1 Approximately 15-20% of patients develop persistent post-concussion syndrome. 5, 1
Multidisciplinary Approach Should Include:
- Formal neuropsychological assessment 5, 1
- Graded physical exercise programs 1
- Vestibular rehabilitation 1
- Manual therapy for cervical spine issues 1
- Psychological treatment 1
- Oculomotor vision treatment 1
Critical consideration: Persistent symptoms are often multifactorial and may involve preexisting mood disorders, learning disabilities, ADHD, or migraine headaches that complicate recovery. 5, 6 Assessment for these comorbidities is essential.
Special Population Considerations
Adolescents and Youth Athletes
- Recovery takes longer than in adults—manage more conservatively 1
- Exercise therapy has the strongest evidence in this age group 5, 3
- Higher risk of academic performance impacts 5
- More susceptible to catastrophic injury if returned prematurely 6
Older Adults
- Often sustain concussions from low-velocity mechanisms (falls from standing) 1
- Age over 40 is a risk factor for persistent symptoms 7
Monitoring and Follow-Up
Instruct patients to return immediately if any of the following develop:
- Repeated vomiting 2
- Worsening headache 2
- Increased confusion or memory problems 2
- Abnormal behavior 2
- Increased sleepiness or difficulty waking 2
- Seizures 2
- New focal neurological deficits 2
Role of Neuropsychological Testing
Neuropsychological testing is not required for most concussions but can provide added value in specific situations. 6 It should never be used in isolation or as a substitute for clinical judgment. 6
When to Consider NP Testing:
- Persistent symptoms beyond expected recovery 1, 6
- Complicated recovery course 6
- Preexisting learning disabilities or ADHD 6
- Multiple prior concussions 6
Critical pitfall: Computerized neuropsychological testing must be interpreted by professionals trained in understanding test limitations, reliable change indices, and false-positive/negative rates. 6
Expected Recovery Timeline
Most patients recover within 7-10 days, though some may take weeks to months. 2 Recovery is typically faster in adults than in adolescents. 1
Prevention of Future Concussions
The most effective prevention strategies involve rule enforcement and behavioral modification, not equipment. 5