What is the appropriate assessment and management for a patient with a suspected concussion?

Concussion Assessment

Any athlete with suspected concussion must be immediately removed from play and undergo structured sideline evaluation using standardized tools—specifically symptom checklists, cognitive testing (SAC), and balance assessment (BESS)—with no same-day return to activity regardless of symptom resolution. 1, 2

Immediate Sideline Evaluation

Recognition Criteria

Suspect concussion if ANY of the following are present after head impact:

Symptoms:

• Headache, dizziness, nausea, or feeling "dinged"/"stunned" 1
• Visual disturbances (seeing stars, double vision) 1
• Balance problems or unsteadiness 1
• Tinnitus, confusion, or memory problems 1

Physical Signs:

• Loss of consciousness (occurs in <10% of concussions) 1
• Poor coordination, gait unsteadiness, or vacant stare 1
• Slurred speech, inappropriate emotions, or decreased playing ability 1
• Concussive convulsion/impact seizure 1

Structured Assessment Tools

Use the SCAT2 or its components (though full SCAT2 validation is pending, rely primarily on SAC scores): 1

1. Symptom Checklist: Document all symptoms and severity using standardized grading 1, 2

2. Standardized Assessment of Concussion (SAC): Tests immediate memory, concentration, and delayed recall—any decrease from baseline is 95% sensitive and 76% specific for concussion 1

3. Balance Error Scoring System (BESS): Test >15 minutes post-exercise in a consistent environment (not on sideline) to improve reliability 1, 2

Critical caveat: Standard orientation questions (time, place, person) are unreliable compared to memory assessment in sports settings 1

Monitoring and Red Flags

• Monitor every 5 minutes from injury until condition clears or referral occurs 2
• Observe for several hours post-injury for deterioration 1, 3

Immediate emergency department referral if:

• Prolonged loss of consciousness 1
• Glasgow Coma Scale <15 at 2 hours post-injury 1
• Suspected skull fracture (open or depressed) 1
• Worsening headache or irritability 1
• Focal neurological deficits or seizure activity 1
• Persistent altered consciousness 1

Neuroimaging Decisions

Routine imaging is NOT indicated for typical concussion—CT and MRI are usually normal 1

Obtain CT scan (preferred in first 24-48 hours) when:

• Structural brain injury suspected based on red flags above 1
• Concern for intracranial hemorrhage or skull fracture 1

MRI is superior for detecting contusions and white matter injury if imaging needed ≥48 hours post-injury 1

Initial Management

Cognitive and Physical Rest

• First 24-48 hours: Complete physical and cognitive rest 2
• Avoid all exertion that provokes symptoms 1
• Implement academic accommodations: reduced workload, extended test time, no screen time if symptomatic 1, 3

Important nuance: While initial rest is critical, prolonged activity restriction beyond symptom resolution may worsen outcomes through deconditioning and psychological effects 4

Medications

• Acetaminophen only for headache (as directed by physician) 2
• Safety and efficacy of other medications not established 1

Return-to-Activity Protocol

Begin ONLY when completely asymptomatic at rest: 2

1. Complete rest until symptom-free
2. Light aerobic exercise (walking, stationary bike)
3. Sport-specific training (no contact)
4. Non-contact drills
5. Full contact practice
6. Return to game play

• Each step requires minimum 24 hours 2
• If symptoms recur at any step, return to previous symptom-free level 2
• No same-day return to play under any circumstances 1, 2, 3

Without standardized assessment tools: Require 7-day symptom-free waiting period before return-to-play 2

Special Populations Requiring Stricter Management

Pediatric/Adolescent Athletes (<18 years)

• Recovery takes longer than adults (weeks to months possible vs. typical 7-10 days) 1
• Risk of catastrophic second-impact syndrome 2, 3
• More conservative return-to-play timeline mandatory 1, 2
• SAC not validated for grade school athletes 1

Athletes with Concussion History

• Increased risk of subsequent injuries and prolonged recovery 2, 3
• More conservative management required 2
• Consider retirement from contact sports with multiple concussions or long-term symptoms 1

Pre-existing Conditions

• Mood disorders, learning disabilities, ADHD, or migraines complicate diagnosis and management 3
• Require more comprehensive evaluation 3

Persistent Symptoms (>3 weeks)

Refer to specialists and implement targeted interventions: 2

• Assess for five concussion subtypes: cognitive, vestibular, ocular, headache/migraine, anxiety/mood 2
• Vestibular rehabilitation for balance/dizziness 2
• Graded physical exercise programs 2
• Manual therapy as appropriate 2

Neuropsychological Testing

Baseline testing is valuable but not mandatory: 1

• Provides objective data but does not alone diagnose concussion or determine return-to-play 1
• Cognitive recovery may precede or follow symptom resolution 1
• Most concussions managed appropriately without neuropsychological testing 3
• Comprehensive testing helpful for persistent symptoms or complicated courses 3

Team-Based Decision Making

Medical clearance required before return-to-play from physician experienced in concussion management: 1, 2

• Integrate physical examination, cognitive testing, balance assessment, and exertional testing 2
• Involve athletic trainers, physicians, specialists, athlete, and family 2
• All evaluators must be trained in standardized test administration 2