What are the guidelines for managing a concussion and how is it identified?

Concussion Identification and Management Guidelines

Immediate Recognition and Removal from Activity

Any athlete with a single concussion symptom must be immediately removed from play and cannot return to activity that same day, regardless of whether symptoms improve. 1, 2

Key Signs and Symptoms to Recognize

Physical Domain:

• Headache (most common symptom) 3
• Nausea or vomiting 2
• Dizziness or balance problems 4
• Visual changes or blurred vision 4
• Sensitivity to light or noise 4

Cognitive Domain:

• Memory problems (retrograde or anterograde amnesia) 4, 2
• Concentration difficulties 4
• Confusion or disorientation 4
• Slowed reaction time 5

Emotional/Behavioral Domain:

• Irritability 4
• Anxiety 4
• Mood disturbances (present in up to one-third of patients acutely) 4

Sleep Domain:

• Sleep disturbances 4
• Drowsiness 4

Critical Red Flags Requiring Emergency Evaluation

Activate emergency medical services immediately if any of these are present: 1, 2

• Loss of consciousness (though this occurs in <10% of concussions) 1, 2
• Worsening or severe headache 1, 2
• Repeated vomiting 1, 2
• Altered mental status or deteriorating neurological status 1, 2
• Seizure activity 1, 2
• Visual changes 1, 2
• Signs of skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak) 1

Initial Assessment Protocol

Cervical Spine Evaluation

Always maintain cervical spine stabilization and evaluate for neck injury first, as concussion and cervical strain share common injury mechanisms. 4, 2

• Check for neck pain and cervical spine tenderness 2
• Assess for radicular symptoms in upper extremities 4
• Palpate occipital region for pain 4

Structured Sideline Assessment

Use standardized tools to document baseline severity: 4

• Symptom checklist with graded severity scale (0-6) across all four domains 4, 2
• Cognitive screening including orientation, immediate and delayed memory, concentration 4, 5
• Balance testing (e.g., Balance Error Scoring System), though recognize this has limited sensitivity 4, 5
• Neurological examination including cranial nerves 4

Memory Assessment

Evaluate both types of amnesia, as their presence indicates more serious injury: 2

• Retrograde amnesia: inability to recall events before the injury 2
• Anterograde amnesia: inability to form new memories after the injury 2

Serial Monitoring

Monitor vital signs and level of consciousness every 5 minutes until condition improves. 4

• Continue monitoring for several days for delayed symptoms 4
• Document time of injury and all serial assessments 4

Diagnostic Considerations

Clinical Diagnosis

Concussion is a clinical diagnosis based on temporal relationship between appropriate mechanism of injury and symptoms—direct head impact is not required. 3, 6

• Results from rotational or angular forces causing shear stress to brain tissue 3
• Represents a functional rather than structural injury 3

Neuroimaging Indications

CT imaging is indicated for: 1

• Glasgow Coma Scale score of 14 or other altered mental status 1
• Signs of basilar skull fracture 1
• Suspected intracranial bleeding 5

Standard concussion without red flags does not require imaging. 5

Subtype Classification

Assess for specific concussion subtypes to guide targeted treatment: 4

• Vestibular subtype (particularly common in pediatric patients) 4
• Ocular-motor dysfunction 4
• Cognitive impairment 4
• Anxiety/mood disturbance 4
• Cervical strain (concomitant injury) 4
• Sleep disturbance (associated condition) 4

Management Protocol

Initial Rest Period

Prescribe 24-48 hours of moderate physical and cognitive rest immediately after injury. 7

• Complete cognitive rest until asymptomatic 2
• This includes limiting screen time, reading, and schoolwork 2

Follow-Up Care

Arrange follow-up with a healthcare professional trained in concussion management within 24-48 hours, even if symptoms appear mild. 1, 2

Academic Accommodations

Students require cognitive rest and academic accommodations while recovering: 5

• Reduced workload 5
• Extended time for tests 5
• Gradual return to full academic demands 5

Symptomatic Treatment

Focus on managing symptoms in affected domains, as there are no specific treatments for concussion itself: 3, 6

• Individualized approach based on which domains are affected 6
• Address headache, sleep disturbances, mood symptoms as they arise 6

Exercise Intervention

Exercise is the only intervention with sufficient evidence for recommendation in adolescents with acute concussion. 7

• Begin after initial rest period and once asymptomatic 7

Return to Play Protocol

Stepwise Progression

Once completely asymptomatic, follow this graded progression: 2, 5

1. Light aerobic exercise (walking, stationary cycling) 2
2. Sport-specific training (skating drills, running drills) 2
3. Non-contact training drills 2
4. Full contact practice 2
5. Game play 2

If any symptoms recur at any step, drop back to the previous level and wait 24 hours before attempting to progress again. 2

Medical Clearance Required

Return to play requires medical clearance from a licensed healthcare provider trained in concussion evaluation and management. 5

Baseline Comparison

When available, compare post-injury testing to baseline measures: 4

• Neurocognitive testing 4
• Postural stability testing 4
• Symptom scores 4

Special Populations

Pediatric Considerations

Children and adolescents require more conservative management: 3

• Longer recovery periods expected 3
• Greater susceptibility to catastrophic injury if returned prematurely 5
• Higher prevalence of vestibular subtype requiring early rehabilitation 4

Athletes with History of Concussion

Previous concussion is a risk factor for: 5

• Higher risk of sustaining another concussion 5
• Potentially prolonged recovery 4, 5
• Possible long-term neurological sequelae with recurrent injuries 5

Complicating Factors

Pre-existing conditions complicate diagnosis and management: 5

• Mood disorders 5
• Learning disorders 5
• ADD/ADHD 5
• Migraine headaches 5

Critical Pitfalls to Avoid

Do not allow same-day return to play even if symptoms resolve—this violates current guidelines and is dangerous. 2, 5

Do not rely solely on loss of consciousness to diagnose concussion—it occurs in less than 10% of cases, and its absence does not rule out concussion. 1, 2

Do not trust athlete self-report alone—athletes frequently minimize symptoms to return to play, particularly males. 2

Do not use neuropsychological testing in isolation—it should only be part of comprehensive concussion management strategy. 5

Do not assume spontaneous recovery—monitor closely for deteriorating status and persistent symptoms requiring specialist referral. 4, 5