Concussion Grading and Management
Modern concussion management has abandoned rigid grading systems in favor of individualized assessment and treatment protocols, with the cornerstone being immediate removal from play, 24-48 hours of moderate rest followed by gradual return to activity, and exercise as the primary evidence-based therapy for adolescents. 1, 2
Historical Context: Why Grading Systems Are Obsolete
Traditional concussion grading scales (Grade 1,2,3) based on loss of consciousness and symptom duration have been largely abandoned because they oversimplify a complex injury and don't predict recovery trajectories. 3, 4 The current approach focuses on individualized symptom assessment across multiple clinical domains rather than arbitrary severity classifications. 3
Immediate On-Field Management
Remove the athlete from play immediately when concussion is suspected—"When in doubt, sit them out." 2, 5
- Never allow same-day return to play, even if symptoms completely resolve. 1, 6, 5, 3
- Monitor vital signs and level of consciousness every 5 minutes until condition improves. 1
- Assess for cervical spine injury concurrently. 1, 5
Red Flags Requiring Emergency Evaluation:
- Loss of consciousness (though this occurs in <10% of concussions) 5, 3
- Altered mental status or deteriorating neurological condition 2, 6, 5
- Repeated vomiting 1, 2, 6
- Severe or worsening headache 1, 2, 6
- Seizure activity 2, 6, 5
- Focal neurological deficits 6, 5
- Signs of skull fracture (Battle's sign, raccoon eyes, hemotympanum, CSF leak) 6, 5
Acute Management Protocol (First 24-48 Hours)
Implement moderate physical and cognitive rest for 24-48 hours, but avoid strict prolonged rest beyond 3 days as this worsens outcomes. 2, 6, 7
Physical Rest:
- No sports, exercise, or strenuous physical activity 6
- Avoid activities that significantly increase heart rate 6
- No contact or collision activities 6
Cognitive Rest:
- Limit screen time (phones, computers, television) 6
- Reduce academic workload 6
- Avoid activities requiring intense concentration 6
Medication Guidelines:
- Use only acetaminophen for symptom management, and only as recommended by a physician. 1, 2
- Avoid all other medications, alcohol, and illicit drugs during recovery. 1
- Do not return to play while taking any medications for concussion symptoms. 1, 2
Gradual Return to Activity (After Initial 24-48 Hours)
Begin supervised, sub-threshold aerobic exercise after the initial rest period—this is the only intervention with strong evidence, particularly in adolescents. 1, 6
Stepwise Progression Protocol:
Each step requires minimum 24 hours and must be symptom-free before advancing: 1, 2
- Light aerobic exercise (walking, swimming, stationary cycling at <70% maximum heart rate) 2, 6, 5
- Sport-specific exercise (skating drills in hockey, running drills in soccer—no head impact) 2, 6, 5
- Non-contact training drills (passing drills, resistance training) 2, 6, 5
- Full-contact practice (following medical clearance only) 2, 6, 5
- Return to competition 2, 6, 5
If symptoms recur at any step, return to the previous asymptomatic level and rest for 24 hours before attempting to progress again. 1, 2
Return to School/Cognitive Activities
Gradually increase academic activities as tolerated, implementing accommodations as needed rather than complete withdrawal from school. 2, 6
Specific Accommodations:
- Shortened school days 2, 6
- Extended time for assignments and tests 2, 6
- Reduced workload 2, 6
- Scheduled breaks during the day 6
- Temporary exemption from standardized testing 2
Assessment Tools for Monitoring Recovery
Use objective assessment tools in combination with symptom checklists—do not rely solely on patient self-report. 1
Recommended Assessment Battery:
- Graded symptom checklists (document number and severity) 1, 5
- Cognitive screening (orientation, memory, concentration) 1, 5
- Balance testing (Balance Error Scoring System) 1
- Neuropsychological testing when available for baseline comparison 1
Baseline testing before injury provides the most reliable benchmark for measuring recovery. 1
Management of Persistent Symptoms (>10 Days)
Implement multidisciplinary management for symptoms persisting beyond 10 days. 1, 2, 6
Approximately 15-20% of patients develop persistent post-concussion syndrome. 6 The multidisciplinary approach should include:
- Formal neuropsychological assessment 6
- Graded physical exercise programs 6
- Vestibular rehabilitation (for dizziness/balance problems) 2
- Oculomotor vision treatment 2
- Manual therapy for cervical strain 2
- Psychological treatment for mood disturbances 2, 6
Special Population Considerations
Pediatric and Adolescent Athletes:
- Manage more conservatively with stricter return-to-play guidelines than adults. 1
- Recovery typically takes longer in younger athletes. 1, 5
- Risk of catastrophic injury (second-impact syndrome) is higher in those under 18 years. 1
- Exercise therapy has the strongest evidence specifically in adolescents. 1
Athletes with Pre-existing Conditions:
- History of prior concussions increases risk of subsequent concussions and prolonged recovery. 3
- Pre-existing mood disorders, learning disabilities, ADHD, or migraines complicate diagnosis and management. 6, 5, 3
Female Athletes:
- Higher reported incidence of concussion in sports with similar playing rules compared to males. 3
Critical Pitfalls to Avoid
Prolonged strict rest beyond 48-72 hours can worsen outcomes through physical deconditioning and psychological consequences of activity restriction. 7
- Returning to activity too soon increases risk of repeat concussion and prolonged recovery. 2
- Relying on loss of consciousness to diagnose concussion (occurs in <10% of cases). 5, 3
- Trusting athlete self-report alone—athletes frequently minimize symptoms to return to play. 5
- Allowing return to play while taking medications for symptoms. 1, 2
- Using online resources for management guidance—these are inconsistent and often contradict evidence-based guidelines. 1, 2
Return to Full Activity Criteria
Clear for return to full activity only when: