What is the proper examination and management protocol for a suspected concussion?

Concussion Examination and Management Protocol

Immediate On-Field Assessment and Removal from Play

Any athlete with suspected concussion must be immediately removed from play and cannot return to competition the same day under any circumstances, even if symptoms resolve. 1, 2, 3

Recognition - Key Signs and Symptoms to Assess

Physical signs to identify:

• Loss of consciousness or altered mental status 1, 3
• Poor coordination, balance problems, or gait unsteadiness 1
• Vacant stare, glassy eyes, or slurred speech 1
• Concussive convulsion/impact seizure 1
• Vomiting or nausea 1, 3
• Inappropriate behavior (running wrong direction, decreased playing ability) 1

Cognitive symptoms to assess:

• Confusion or disorientation 1
• Memory problems (retrograde or anterograde amnesia) 1, 4
• Slow to answer questions or follow directions 1
• Poor concentration or easily distracted 1

Patient-reported symptoms to document:

• Headache (most common) 1, 2
• Dizziness or feeling "in a fog" 1
• Visual disturbances (seeing stars, double vision, blurred vision) 1
• Ringing in ears 1
• Sensitivity to light or noise 3
• Sleep disturbances or feeling slowed down 1

Structured Sideline Examination

Use a graded symptom checklist to objectively document symptom presence and severity. 1, 4 This provides baseline documentation for serial assessments and tracks recovery over time.

Perform cognitive assessment including: 1, 4

• Orientation (person, place, time, situation)
• Immediate memory (repeat word lists)
• Concentration (digits backward, months in reverse)
• Delayed recall (remember earlier word lists)

Conduct balance testing (recognizing this is specific but not sensitive for concussion). 1, 4 Note that sideline balance testing may differ from baseline due to footwear, surface, ankle tape/braces, or other lower extremity injuries. 4

Monitor vital signs and level of consciousness every 5 minutes until condition improves. 1

Emergency Red Flags Requiring Immediate CT and Hospital Evaluation

Transport immediately to emergency department if any of the following develop: 1, 2, 3

• Prolonged loss of consciousness (>1 minute) 3
• Deteriorating mental status or increasing confusion 1, 3
• Focal neurological deficits (weakness, numbness, vision changes) 1, 3
• Severe or progressively worsening headache 1, 2, 3
• Repeated vomiting (>2 episodes) 1, 2, 3
• Seizure activity 1, 2, 3
• Signs of skull fracture or scalp swelling 2, 3
• GCS <15 at any point 3

CT imaging is indicated for these high-risk features but contributes little to routine concussion evaluation in stable patients. 1, 3

Initial Management: The First 24-48 Hours

Prescribe complete physical and cognitive rest for 24-48 hours immediately after injury. 2, 3 This is the only period where strict rest is beneficial; prolonged rest beyond 48-72 hours can worsen outcomes. 1, 2, 3, 5

Physical rest means: 3

• No sports, exercise, or strenuous physical activity
• Avoid activities that significantly increase heart rate
• No contact or collision activities

Cognitive rest means: 2, 3

• Limit screen time (reading, video games, computer, television)
• Reduce exposure to loud music and bright lights
• Minimize activities requiring intense concentration

Medication management: 2

• Acetaminophen only, and only as recommended by physician
• Avoid all other medications, alcohol, and illicit drugs
• Never allow return to play while taking any medications for concussion symptoms

Implement academic accommodations immediately: 1, 2, 3

• Shortened school days
• Reduced workload and extended time for assignments
• Postponement of standardized testing
• Breaks during the day as needed

Graduated Return-to-Activity Protocol

Once asymptomatic at rest for 24 hours, begin the stepwise progression. Each step requires a minimum of 24 hours, meaning the fastest possible return to competition is 5 days. 1, 2

If any symptoms recur at any stage, immediately stop activity, rest for 24 hours after becoming asymptomatic again, then restart at the previous asymptomatic level. 1, 2

Six-Step Return-to-Play Protocol

Step 1: No activity - Complete physical and cognitive rest until asymptomatic at rest 1

Step 2: Light aerobic exercise - Walking, swimming, or stationary cycling at <70% maximum heart rate; no resistance training 1, 2

Step 3: Sport-specific exercise - Sport-related drills (skating, running) but absolutely no head impact activities 1, 2

Step 4: Non-contact training drills - More complex drills; may start light resistance training 1, 2

Step 5: Full-contact practice - Only after medical clearance; participate in normal training 1, 2

Step 6: Return to competition - Normal game play 1, 2

Objective Testing to Guide Return-to-Play

Baseline neuropsychological testing before the season provides the most reliable benchmark for measuring post-injury recovery. 1, 4 Without baseline data, interpretation is less reliable due to individual variability, learning disabilities, ADHD, and effects of prior concussions. 1, 4

Computerized neuropsychological testing should be interpreted only by healthcare professionals trained in the specific test, understanding its limitations including reliable change index, baseline variability, and false-positive/negative rates. 1, 4

Paper-and-pencil neuropsychological tests are more comprehensive, test different cognitive domains, and can assess for conditions that masquerade as or complicate concussion. 1, 4

Neuropsychological testing should never be used in isolation but only as part of comprehensive concussion management. 1, 4 Most concussions can be managed appropriately without neuropsychological testing. 4

Balance testing provides objective assessment of postural stability but has limitations. 1, 4 It is specific but not sensitive for concussion. 4

Management of Persistent Symptoms (>10 Days)

Approximately 15-20% of patients develop persistent post-concussion syndrome requiring multidisciplinary management. 2, 3

Implement the following interventions for prolonged symptoms: 2, 3

• Formal neuropsychological assessment for persistent cognitive symptoms
• Graded physical exercise programs under professional supervision (strong evidence in adolescents) 1, 3
• Vestibular rehabilitation for balance and dizziness symptoms
• Manual therapy for cervical spine symptoms
• Assessment for preexisting comorbidities (mood disorders, learning disabilities, ADHD, migraine) that complicate recovery 3, 4

Special Population Considerations

Pediatric and adolescent athletes require more conservative management with longer cognitive recovery periods (7-10 days or longer) compared to college-aged or professional athletes. 1, 2, 3 Damage to the maturing brain can be catastrophic. 2

Female athletes have higher reported concussion incidence than male athletes in sports with similar rules. 4

Athletes with history of multiple concussions (≥3) who experience slowed recovery may require temporary or permanent disqualification from contact sports. 2, 4

Athletes with preexisting mood disorders, learning disorders, ADHD, or migraine headaches require careful assessment as these conditions complicate diagnosis and management. 3, 4

Absolute Contraindications to Return-to-Play

Do not clear for return to play if: 2, 3

• Any symptoms present at rest
• Symptoms occur with exertion at any level
• Taking any medications for concussion symptoms
• Cognitive function has not returned to baseline (preferably documented by neuropsychological testing)
• Has not completed the full 6-step graduated protocol
• Lacks medical clearance from licensed healthcare provider experienced in concussion management

Critical Pitfalls to Avoid

The most dangerous error is allowing premature return to play, which risks second-impact syndrome, worsens outcomes, and prolongs recovery. 2, 3 The phrase "When in doubt, sit them out" is paramount. 1, 2

Do not prescribe strict rest beyond 48-72 hours, as prolonged activity restriction can worsen outcomes through physical deconditioning and psychological consequences of removal from validating life activities. 1, 2, 3, 5

Do not skip steps in the return-to-play protocol. 2, 3 Each step must take at least 24 hours.

Do not rely solely on patient self-report, as athletes may underreport symptoms to return to play sooner or overreport leading to unnecessarily prolonged restriction. 1

Do not underestimate recovery time in younger athletes, who require 7-10 days or longer for full cognitive recovery even when asymptomatic. 1, 2, 3

Do not fail to identify and manage symptoms persisting beyond 10 days with appropriate multidisciplinary interventions. 2, 3

Documentation and Monitoring

Document the time of initial injury and perform serial assessments noting presence or absence of all signs and symptoms. 1 This creates a timeline for recovery and medicolegal protection.

Monitor the athlete for several days after injury for delayed signs and symptoms. 1 Provide written discharge instructions to patient and family about warning signs requiring emergency evaluation. 2, 3

All training and conditioning sessions during recovery should be documented. 1

Prevention Considerations

Helmets prevent skull fractures and intracranial bleeding but have not been consistently shown to reduce concussion incidence or severity. 1, 3, 4 Newer helmet technology shows promise but requires further independent research. 1

Primary prevention is best achieved through rule modification and enforcement, and behavioral changes promoting fair play, not through equipment. 3, 4

Secondary prevention occurs through appropriate return-to-play management preventing repeat injury during the vulnerable recovery period. 4